Many types of scalp reduction techniques have been described and used in the past for the treatment of alopecia, correction of male-pattern baldness, or areas of thinness. Such techniques included flap advancement, flap rotation, and sometimes tissue expansion. Those techniques are still part of the plastic surgeon’s armamentarium, yet different hair transplant techniques, such as follicular extraction, have become mainstream. That is, if the patient has a dense “hair donor” site.
I perform several forehead reduction procedures every year for men and women, but also for my MTF transgender patients. Most of these individuals have high foreheads and would benefit from forehead reduction and brow lift and potentially frontal bossing reduction, an element of facial feminization surgery.
Many aesthetic brow lifting procedures can be done within the hair itself. In these cases, lifting of the brow is the primary goal. However, it will always lift the hairline up, potentially aging or masculinizing a patient’s appearance. Should the patient have a low hairline, it will not be an issue. But for patients with high hairlines, I recommend an incision at the hairline itself.
In forehead reduction, a hairline incision technique has a different goal: reducing the height of the forehead and advancing the scalp forward. It involves removing hairless skin from the forehead proper, freeing (undermining) the posterior scalp, scoring and releasing deeper tissues, and advancing the scalp anteriorly, reducing forehead height. One can expect a total reduction of between 1.5 and 2.5 centimeters. For many patients, this makes a world of difference.
The incision and final scar are very important to both the plastic surgeon and the patient. The aesthetic surgeon has to take into consideration the direction of the hair follicles and must perform a very meticulous closure, in 2 or 3 layers, as to minimize tension on the skin itself for a fine scar. I also like to do mini zigzags at the hairline to avoid a completely straight line, which looks less natural. Each patient must be prepared to temporarily change his or her hairstyle to cover fresh scars. All scars tend to be pinker for a few months after surgery and will slowly fade to white scars over 6 to 12 months.