Hairline lowering surgery (forehead reduction)
Table of contents:
The hairline is an identifying trait for gender, and is accentuated by age. Forehead reduction and contouring, also called hairline lowering, is an important procedure of facial feminization surgery.
The female hairline varies in position. Ideally, the hairline would be positioned 5 to 6.5 cm above the brows. It would begin at the point where the scalp slopes from a more horizontal position to a more vertical position. In males, the average hairline is higher.
Apart from the position, the shape of the hairline is different as well. A man usually has receded temples that give the hairline an “M” shape. Conversely, the female hair pattern is oval-shaped. It is smoother and full around the facial edge.
Hairline aging pattern
An additional difference between male and female hairlines comes with age. There is a typical male pattern of baldness with a recession of the hairline. This is something that usually won't occur in women. While biological women sometimes do suffer from hair loss, it is usually an all-over thinning of the hair from the entire scalp and isn’t specifically targeted to one area.
There are 3 hairline lowering options. The following indications suggest which option would be recommended for you.
1 Hair transplants
- Only the receding temples have to be filled (the M-shape as seen above). No overall lowering is needed.
- After a surgical forehead reduction, often one still has receding temples that can be filled with transplants (fewer transplants needed).
- Covering of the forehead reduction scar—Most of the time, the scar from a forehead reduction becomes as good as invisible after 1 year. However, there are patients whose scar remains visible. This can always be hidden by placing some implants over and before the scar.
2 Surgical hairline lowering one stage procedure
- Flexible scalp—The flexibility of the scalp determines how much the hairline can be advanced. The hairline will be advanced as much as is possible to then be able to close the wound without tension. Normally this will provide an advancement of 0,5 to 1 cm. With a very flexible scalp, advancements up to 2 cm are possible.
- Forehead recontouring—To lift the excess skin after the removal of the frontal bossing, a strip of hair-bearing skin needs to be removed. If the incision is made behind the hairline, this would cause the hairline to recede more. That is why we mostly recommend doing the forehead reduction procedure as well if you get a forehead recontouring. The lowering effect might be minimal, but at least the hairline won’t go up.
3 Surgical hairline lowering with tissue expander (two stages)
- Large advancement—There would be a lot of tension on the wounds if the hairline would be advanced for more than 1,5 cm. This would cause a wide scar. The solution could be a balloon implanted underneath the skin on the back of the head. The balloon will gradually be filled with water, causing the creation of new hair-bearing skin. This new skin allows for the tension-free removal of the non-hair-bearing skin to lower the hairline. With an expander, a tension-free hairline lowering until about 8cm is possible.
- High receding temples.
- Very tight scalp which would barely give way to any advancement with the hairline lowering procedure in one stage.
Hairline lowering in one stage
- Surgical drawing—The surgical drawing is made.
- General anesthesia is performed.
- Incision—An incision is made along the hairline. The incision is made just inside the hairline, in an irregular fashion, to avoid a straight scar. Straight scars are more conspicuous than irregularly curved ones. The blade is also drawn in such a manner that about six weeks after the surgery, the hair starts growing through the scar, making it nearly invisible.
- Removal—A section of forehead skin at the hairline is removed.
- Mobilization—The scalp will be detached from the skull and pulled forward. Normally an advancement of 1 to 1.5 cm can be achieved.
- Fixation—The scalp is fixed to the bone using Endotines to prevent it from pulling back. This device is made of a bioabsorbable material and dissolves over time.
- On the day of the procedure and the day after, the patient might experience slight pain or discomfort. This can be well managed with the painkillers we will provide you with.
- The first week—During the first week there might be a bit of swelling and bruising but it won't be very noticeable. If staples have been used, they will be removed after 7 days. Patients from abroad can return home the same day. The staples can be removed in their home country by a general practitioner. The stitches that we use are self absorbable.
- Subsequent weeks
- Sutures—After 2–3 weeks the absorbable sutures at the hairline will fall out.
- Scar—The scar will remain red and elevated for a period of 2-6 months. After about 6 weeks small hairs will start to grow through the scar, making it less visible.
- Numbness—All patients experience numbness of the front of the scalp. Sensation will return within 3 to 12 months. Sometimes there is an itching sensation during the recovery period.
- Temporary loss of hair—There can be some shedding of the fine hairs in the front of the scalp within 2-4 weeks after surgery. This is called an “effluvium”. The hair normally grows back after 3 months. We sometimes suggest the use of 5% Minoxidil to the front of the hair-bearing scalp after surgery. This can lessen the possible hair loss and promote more rapid growth of hair that might have been shed and of hair that will be growing through the incision.
- Full recovery—Full recovery is to be expected after 12-18 months when the scar will have reached its full maturity. There will be a visible scar, but it is usually too faint to even notice after one year.
- General hair thinning—This complication has been reported by 1% of patients.
- Scar—Sometimes the tension on the incision is so big, a visible scar develops. In that case, a scar revision surgery has to be performed.
- Diminished scalp sensation—It is possible the scalp sensation is diminished permanently. The patients who mention this don’t experience this as a problem.
Hairline lowering with tissue expander
If the scalp is tight, or more than 2 cm of advancement is needed, or the receded temples are very significat, the following two-stage procedure can be considered. This technique has been developed by Dr. Kabaker and has been used for over 20 years. It has proved to be almost instantly effective and is well tolerated by patients.
Tissue expansion is a procedure commonly used in reconstructive surgery to repair burn wounds and injuries with significant skin loss. Its use in hair replacement surgery has generated dramatic results because it gives significant coverage in a relatively short amount of time.
Skin expansion is a common surgical procedure to grow extra skin through controlled mechanical overstretch. It creates skin that matches the color, texture, and thickness of the surrounding tissue while minimizing scars and risk of rejection.
In this technique, a balloon-like device called a tissue expander is inserted beneath the hair-bearing scalp that is next to a bald area. The device is gradually inflated with salt-water over a period of weeks, causing the skin to expand and grow new skin cells. This causes a bulge beneath the hair-bearing scalp, especially after several weeks.
When the skin beneath the hair has stretched enough, usually about two months after the first operation, another procedure is performed to bring the expanded skin over to cover the adjacent bald area.
1 First operation (placement of expander)
During the first operation, the croissant-shaped expander is inserted under the hair-bearing skin and filled up to 120ml.
2 Filling of the expander
The balloon is expanded over a 7-week period to stretch the scalp sufficiently to allow for 4-8 cm of advancement. Hair-bearing tissue can be expanded to approximately twice its size without a noticeable deficit in hair density.
This is well tolerated by patients aside from the cosmetic inconvenience during the last three weeks of the expansion.
3 Second operation (hairline lowering)
During the second and final surgery, the device gets removed and the expanded hair-bearing scalp is moved forward, replacing the top section of the high forehead or the significantly receded temples. With this approach, we are able to move the hairline forward as far as 8 cm and close these receded temples. The procedure of this hairline lowering surgery is performed the same way as the simple one stage hairline lowering surgery, as explained above.
- Temporary hair loss may occur.
- Shifting of the expander, which never really forms a problem.
- Rare complications can be skin necrosis if expanded too fast. This can be avoided by carefully following the instructions given by Dr Bart van de Ven.
- If a minor skin perforation is made by accident during surgery, the expansion may become impossible to execute.
Frequently asked questions
What does this procedure cost?
There are 3 options to receive a financial and operative proposal. You can either send us pictures and receive a quote and an FFS simulation, or you can book a Skype or a live consultation with Dr Bart van de Ven during which you will also receive a quote and FFS simulation. Click here if you want to get a general idea of FFS prices.
What happens if there are complications after the procedure and is this covered?
We will correct the complication if surgically possible, without charging any surgical fees. Hospital, material and traveling costs are for the expense of the patient.
Can I lose feeling (numbness) permanently in some areas following FFS surgery?
Some temporary numbness in any of the areas where bone work is done is an absolute certainty. That could include the scalp, forehead, chin, jaw or even cheek areas depending on where the surgery has been done. This happens because the flesh is detached from the bony area. Several thousand minor nerves are severed, and it will obviously take some while for those areas to heal. Up to 18 months of recovery time is not unusual, but it usually takes less time. You may not regain the same level of feeling as before.
Can I get this surgery if I’m a cis woman?
Yes, of course. We perform Facial Feminization Surgery on all women. Every woman is welcome at our clinic!
What are the chances that I will experience hair loss after the operation?
Many patients experience temporary hair loss. The hair loss just behind the hairline is caused by a reduced blood supply. The reduced blood supply is caused by the incision itself which cuts off the blood supply from the front and by the tension caused by the hairline lowering. The hair loss is at its maximum after about 1 month. Sprouting of blood vessels across the scar will create a new blood supply from the front and as tissues relax the tension will go down. This will ultimately result in a regrowth of the hair. To what extent and how long it will take varies per patient but in general most of the lost hair will be back after 6 months. If you want to do something about it you could use some Minoxidil lotion. You can start Minoxidil after proper healing of the incision wounds, three to four weeks after surgery.
How soon after hair restoration (crown/hairline) can chemical hair color be applied/can I dye my hair again?
You can dye your hair again after 6 weeks.
Is it possible to have hair replacement done at the same time as the procedure to give a female hairline?
If you only get a hairline lowering it basically is possible to get a hair transplantation at the same time.
How long does it take until the sutures in my hairline dissolve?
The white skin sutures dissolve in 1 or 2 weeks. If they would still be in the skin after 2 weeks they will easily break when you pull with your fingers.
When can I start dying my hair again?
Before you can start stain your hair again after a forehead recontouring the incision should have healed 100%. If the incision was made a few cm inside the hair (no hairline lowering) this will take about 6 weeks. In case you had a hairline lowering this might take longer (up to 4 months).
How long does it take for the final result to be visible and the bruises to disappear completely?
Recovery looks different for every patient, but bruising usually disappears after two to four weeks. The final result can be visible after a few months, but it may also take longer than a year. All information on recovering from FFS can be found on our recovery page.
When can I start using Minoxidil on my hair after forehead reduction or hairline lowering?
You can start Minoxidil after proper healing of the incision wounds, three to four weeks after surgery.
After a hairline lowering and brow lift I now have bumps along my hairline which are irritating, do these settle down?
Those bumps are the Endotines that have been placed just inside the hair to prevent the hairline from pulling back. They will dissolve in about a year, sometimes even a bit more.
How long does it take for the endotines to disappear?
According to the manufacturer it takes about 3-6 months for the endotines to absorb. According to our experience it takes about 6-18 months before the endotines dissolve completely.
When can I wash my hair?
Almost immediately. Don’t be alarmed if the wound bleeds a little bit while washing your hair. For wound healing it’s very good to remove all excessive blood clots and crusts, even better when you use shampoo. Just remember to blow-dry thoroughly and dab with a drying antiseptic, like alcohol, afterwards to eliminate any remaining moisture.
Is it common to have complications during the expansion?
Complications during expansion have become very rare since we place the expander on the back of the head. Leakage of the expander or a serious infection have never occurred.
How much time should there be between the placement of the expander and the actual hairline lowering?
Depending on the amount of hairline lowering necessary you will need 6–8 weeks for the expansion.
How often should I inflate the expander?
You will have to inflate the expander twice a day with 10ml of water (saline). We will supply you with all the necessary equipment after the expander has been placed.
Is the expansion very painful or disfiguring?
Thanks to a new technique developed by Dr van de Ven the expander can be placed on the back of your head. With the new technique, patients don’t complain of pain during the expansion anymore and it has become much easier to hide the expander.
We are doing our very best to keep this information up-to-date. In case you see anything that no longer seems accurate, or in case you have a question, please fill out the form below!