With classic facial proportions the forehead should comprise one third of the face. In the female patient with a high hairline it masculinizes them and limits their ability to style the hair so they frequently use bangs to camouflage the undesirable large forehead. In women this is frequently an inherited characteristic but also may be secondary to previous cosmetic surgery. With men this can be an inherited characteristic or the result of progressive male pattern baldness.
There are several procedures and combinations of procedures that can be used to reduce the size of the forehead and improve facial proportions.
Despite many claims by other surgeons, this technique was developed and described by Dr. Fleming and Dr. Mayer over thirty years ago. With this technique an incision is made within the soft hairs at the hairline, the scalp is mobilized then advanced inferiorly lower on the forehead. Forehead skin below the old hairline is excised and the new hairline established. Using the Irregular Trichophytic Hairline Incision, hair follicles are buried under the skin closure at the completion of the operation so hair will grow through the front of the hairline, giving patients total freedom of hair styling. The scar from this incision will not be visible. In some instances, where there is not enough elasticity in the scalp to provide adequate advancement, a tissue expander can be placed under the hair bearing scalp. This expander is slowly filled and over time will stretch the scalp to provide the needed advancement necessary to lower the hairline. After several weeks the tissue expander is removed and the hairline is advanced to the correct position.
EYE BROW AND FOREHEAD LIFT
In patients who complain of a tired or sad appearance because of the low position of their eyebrows either as an inherited characteristic or secondary to the natural aging process, the brows can be elevated. The forehead grooves and fine lines can accentuate the problem by making the person appear angry or fatigued.
In these patients, the brows can be lifted and the forehead grooves reduced using either of two separate techniques. The endoscopic lift, which is done through several small incisions within the hair bearing scalp can be used to lift the brows but this will also elevate the hairline and therefore not reduce the size of the patient’s forehead. A brow lift can also be achieved using the Irregular Trichophytic Hairline Incision that we described for hairline lowering. Using this incision we can lift the brows and either maintain or lower the hairline position achieving even greater forehead reduction if desirable.
ORBITAL BONY CONTOURING
In many female and some male patients, there is excessive fullness of the forehead bones immediately above the eyebrows. This bone can be contoured and reduced during the forehead or eyebrow lift. This is done through the same hairline incision which we previously described so ultimately no scar will be visible.
HAIR REPLACEMENT SURGERY
Hair replacement surgery is sometimes necessary to reduce the size of the forehead. This can be accomplished using hair transplants or the Fleming Mayer Flap which will provide normal, uniform thick density to frame the face.
All of these techniques are combined and modified to meet the needs of each individual patients so that forehead reduction can be achieved to improve facial proportions and forehead contours.