Hairline lowering surgery (forehead reduction)

The hairline is an identifying trait for gender, and is accentuated by age. Hairline lowering, also called forehead reduction or contouring, is an important procedure of Facial Feminization Surgery.

Gender of the hairline

Understanding the differences between male and female hairlines is of critical importance in hair transplants or hairline lowering surgery for both women and transwomen as this is necessary to create a natural appearance.

Male and female hairs differ in position, shape, ageing pattern and directional flow of hairs.

Read more on the differences between male and female hairlines.

How to feminize the hairline?

There are 2 hairline contouring 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.
• Usually, 2 sessions are needed to get a natural looking result (which requires 50 to 60 hairs per cm²). Per session, we can implant a maximum of 40 hairs per cm².
• You can choose between the FUE method with shaving the extraction site (e.g. the back of the head) or the FUE method without shaving the extraction site. The latter method is suitable for smaller areas.
• After a surgical forehead reduction, often one still has receding temples that can be filled with transplants (fewer transplants needed).
• Covering of the hairline procedure 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 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.
• Frontal bossing reduction—This is the most common indication in our practice. To lift the excess skin after the removal of the frontal bossing bone, a strip of 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 hairline procedure as well if you get a frontal bossing reduction. The lowering effect might be minimal, but at least the hairline won’t go up.

BeforeAfter

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Hairline lowering in detail

Procedure

• Mostly performed in general anaesthesia
  
• Surgical drawing—The surgical drawing is made.
• 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 angle of the incision is also oblique in such a manner that about six weeks after the surgery, the hair starts growing through the scar, making it nearly invisible.

The angle of the incision is also oblique in such a manner that about six weeks after the surgery, the hair starts growing through the scar, making it nearly invisible.

• Skin 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.

Recovery

• 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.
• To prevent infection, we recommend taking azithromycin once a day after meals for the first 3 days after surgery.
• 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.

Complications

• 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.
• Infection (e.g. staphylococcus aureus)—As with any surgery, infection can occur (see photo below). With hairline lowering surgery, it can be extra tricky to keep the surgical area clean and sterile during aftercare. Tiny hairs can grow inward into or below the skin which can cause irritation or infection. Usually these tiny hairs can be removed using sterile tweezers. In case of an infection, we advise you to:
  • use Floxapen 500mg (flucloxacillin) 4 times a day during 14 days;
  • use Fucidin ointment for 14 days;
  • clean the wound twice a day with chlorhexidine in water;
  • use Flaminal or Flammazine ointment on the wound twice a day;
  • to send an evaluation of the treatment after 10 days by sending pictures to Dr. van de Ven.

An example of an infection due to staphylococcus aureus

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Frequently asked questions

• What does this procedure cost?

  You can find estimated prices here, after your consultation you will be informed of the exact prices of your operation. Prices are average and may vary depending on the exact treatment. 

  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 soft tissue 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 2 months. Before you can start dying your hair again, the incision should have healed 100%.

• 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 dying 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 to 8 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.

• 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 are  complaining less of pain during the expansion anymore and it has become much easier to hide the expander.

• What are the complications after having hairline lowering surgery?

  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. 

  Infection (e.g. S. Aureus)—As with any surgery, infection can occur. We advise you to: 1. use Floxapen 500mg (flucloxacillin) 4 times a day during 14 days; 2. use Fucidin ointment for 14 days; 3. clean the wound twice a day with chlorhexidine in water; 4. use Flaminal or Flammazine ointment on the wound twice a day; 5. to send an evaluation of the treatment after 10 days by sending pictures to Dr. van de Ven.

• Am I a suitable candidate for PRP treatment?

  Unfortunately, not everyone is eligible for this treatment. We do not recommend PRP treatment if you: suffer from an active scalp infection such as eczema or shingles | are diabetic | suffer from a coagulation disorder | take blood thinners. Not sure if you are eligible? Feel free to discuss it with our doctor.

• What are the advantages and disadvantages of PRP treatment?

  On the positive side, your own blood is used, so the risk of infections or allergic reactions is very low. Moreover, it is a non-surgical treatment that is safe and has positive results. Recovery is also very quick. 

  A disadvantage of the treatment is that not everyone can have it, that it does not work equally well with everyone and that the number of treatments needed varies greatly from person to person. 

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!