Hairline Lowering, Filling, and Rounding Out Options? (photo)

There are two techniques for advancing the overly high hairline- hair grafting, and the surgical hairline advancement (SHA).  Few doctors offer both of these procedures, but given my experience as a facial plastic surgeon specializing in hair restoration, it makes sense that I can not only offer them to my patients, but also specialize in performing them.

 

The SHA technique is a 2 hour procedure performed usually under local anesthesia with some oral sedation (but if desired, can be performed under intravenous sedation) that involves making an incision along the hairline and advancing it, lowering it by as much as 1 ½ inches (3.5 cm) or more in a single procedure, removing the excessively high forehead skin, with virtually instantaneous results.   The sutures along the hairline are removed at 5 to 7 days, leaving a fine line scar that is designed so that hairs actually grow through it.  To secure the advanced hairline in its more forward position, oftentimes small Endotine" hooks are placed below the scalp, which dissolve after 4 to 6 months (they cannot be felt unless you push down directly on them).  This procedure is best for patients with a flexible scalp to allow for sufficient advancement, and can be combined with a browlift for patients desiring a more youthful eye region if the eyebrows have fallen with age.  To assess your scalp laxity, you need to place your index finger right on the midaspect of your hairline, and see how far it can move back and forth-  this total excursion is a reasonable estimate of just how far the scalp can be advanced with the SHA.  Another requirement for being a good candidate is that there should not be any thinning of the frontal hairline, and that the hairline hairs are stable.   Lastly, some patients choose to undergo hair grafting after the SHA to both round out the hairline, allowing filling in of the temporal regions, as well as to help further conceal the fine line scar that may be visible in the occasional patient.  This grafting can be performed as soon as 3 months after the SHA, and typically ranges from 300 to as many as 800 grafts.

The more commonly chosen procedure to advance the overly high hairline is hair grafting.  This is a typically less "surgical" procedure, involving the transplanting of 1200 to as many as 2400 grafts (depending on how much lowering is desired) in a single procedure, taking 3 to as many as 8 hours to perform (it is a very meticulous procedure).  Every graft is placed into tiny recipient sites (0.5 to 0.8 mm in size) each one made by me- these sites then determine the direction, pattern, and angulation of growth to assure a natural appearance.  The transplanted hairs typically fall out within 3 weeks, then start to regrow at 4 months, taking a full 10 months or longer for final results.  The hair grafting procedure is ideal for hairlines that are thin or thinning out, for those who want a hairline that not only is lower but also is more rounded, and for those who opt not to have or are not good candidates for the SHA.

 

In your case, you appear to be a better candidate for hair grafting.  I'd anticipate a procedure of 1500 to 1700 or so  grafts to fill in the area I have marked out on the attached photos in blue, achieving a natural appearance and moderate density.  Some patients desire a second procedure in 10 plus months to achieve greater density, while most patients find the density after a single procedure to  be satisfactory.

You would need an examination to make sure you would be a candidate.You can review the VIDEO of women who had the hair line lowering to gauge what is possible.

Forehead lowering is a surgical procedure where the scalp is lifted up through an incision along the hairline and undermined posteriorly extensively. The scalp is then pulled forward into the new position and the excess forehead skin is trimmed.The cowslick could be removed during the procedure if you wish.

Various techniques are used to stretch the scalp in surgery. The deeper tough layer (galea) is incised from side to side to allow stretching of the scalp. Usually tissue expanders are not needed for even significant advancement. This is much more effective than hair grafting and probably would cost less.

The procedure does cause some numbness of the scalp behind the incision, but this does not appear to be a problem and does not bother people that have had the procedure. I would encourage you to find a surgeon that has experience with this operation rather than having hair grafting.

Search out a good hair graft doctor.  I strongly recommend Neograft that allows single follicle harvest.  Forehead reduction is also an option however that does leave a fine scar along your hairline. 

Lowering your hairline the desired 1-1.5 inches while designing a natural-looking new hairline should be possible via FUE hair transplant and would be your best bet in terms of minimized scarring. However, candidacy for the procedure and the practicality of your goal depend on a few variables, one of them being the density of the hair on the back/sides of your scalp. If you decide to seriously pursue hair grafts, I advise you to seek multiple consultations with various FUE hairline specialists. Best of luck to you.

Unless you have Avery elastic scalp you need a tissue expander. We developed this surgery 25 years ago along with The Irregular Trichophytic Forehead Lift  and Hairline Lowering. This is done in such a way as to have hair grow THRU the scar instead of behind it. 

As a certified facial cosmetic and reconstructive surgeon who also specializes in hair restoration, I can expertly perform the different options you have researched.  When someone considers a forehead lift or facelift, I assess the skin elasticity to anticipate risks of relative scarring that can occur from a procedure like a reverse forehead lift or even a hair transplantation procedure. In your case, for both practical and cost reasons, I recommend hair grafting.

To create a lower hairline, you have to be mindful of how close the hairs are placed in order to make it look natural.  A good strategy is to slowly lower the hairline from the point where it is most dense and transition it from there downward. This is based on the number of grafts that are available as well as the thickness and quality of the hair. In a cowlick, a procedure that might be helpful is to take hairs from the cowlick and transplant them in a different direction to get better coverage.

In traditional hair transplantation, there are hairs that don’t make it because of the type of hair, the surgical technique employed and the amount of bleeding that occurred. So in our practice, we use a material called ACell extracellular matrix which aids in healing by the duplication of tissue. This results in the activation of adult stem cells. In addition, the adult stem cell known as progenitor cells which become less capable or become defective will make hair follicles susceptible to dihydrotestosterone (DHT) the hormone that causes hair loss . Extracellular matrix and platelet-rich plasma formulation of the Hair Regeneration injection stimulates production of progenitor cells, thereby protecting the hair from the hair loss effect of DHT. So extracellular matrix is a good intervention to reverse male or female pattern hairloss and would contribute to the thickening of the hair.

The forehead lowering is not a simple procedure.  Scalp advancement, or reverse forehead lift, with or without tissue expanders is an involved procedure that will leave a scar at least at the hairline.  It can be successful but is a two stage procedure when tissue expanders are involved. 

 

Hair transplantation can also be very successful but lowering it a full inch can be difficult if not impossible.  IT would be ambitious and may need to be done in more than one procedure.  The hairline can be lowered less agressively with great success and this may be enough to change the appearance significantly with one procedure

For hair transplant lowering procedure, the number of sessions
varies by the thickness of the hair. For women with other than fine hair, they
might do this in a single session. With finer hair, it often takes two
sessions. The time to see the impact of a hairline lowering hair transplant
procedure is 7-8 months and if a second session is required, it will take
another 7-8 months to wait for full growth. See web-references below for four
excellent sets of photos of this process on four women.

The pictures give us a good idea of the high hairline you describe and the concerns you have for the sparse temple hair.

If you have great laxity of your scalp and forehead tissues, a one stage advancement procedure could give you a near instantaneous result for the least amount of cost. If the scalp is tight, a preliminary expander insertion operation is required  and a 6 week period  of expansion would allow for as much hairline advancement as you might want . It is rare for the scalp to allow for the desired 1.5 inches of lowering in the single stage procedure. If you can actually pinch up a fold of forehead skin below the hairline from top to bottom so that the skin meets back to back, you might have the  ideal situation .

Hair transplants are a definite alternative, taking up to a year and a half for the growth to be long enough to contribute to your hair styling. Usually 2 transplant sessions are necessary to get the density that you might want. If you have a strip harvest hair transplant, it is unlikely you could be a candidate for the hairline advancement operation afterwards.  

The cowlick you describe merits attention and modifications to any approach to your problem. The sparse hairs in the temples might require transplants in any case  scenario. These can be done in the same session(s) as a surgical advancement of the frontal hairline while not adding any additional donor scars.