Best Hairline Lowering Technique for Hairline Feminization

Hairline lowering techniques are commonly used during facial feminization surgery (Facial Feminization Surgery). In particular, the are used as a part of forehead feminization (Forehead Feminization). In general, hairline lowering is commonly performed through either a scalp advancement or with the use of hair transplants.

When forehead bone reduction is performed, the surgeon usually accesses the site through one of two incisions. These two incisions include a hairline incision or an incision that is behind the hairline (coronal incision). They each have their own advantages and disadvantages depending on the goals of the operation.

Surgical Hairline Lowering, Coronal Incision, Hair Transplants

Hairline incision for hairline lowering (aka pretrichial incision)

A hairline incision is one that follows the middle hairline on the forehead. This is often used to perform a scalp advancement or hairline lowering. When a hairline incision is used, the design below is commonly employed.

Coronal incision

When hairline lowering is not necessary for facial feminization, a coronal incision is often used. This incision is placed within the hair to prevent it from being seen. The hair often easily covers up the scar that results from this incision.

Hair transplantation for hairline lowering

Hair transplantations can be performed before, during, or after facial feminization surgery. When performed intraoperatively, a strip of scalp can be removed that is then used for harvesting hair follicles. The hair follicles are then implanted during the remainder of the operation. Hair transplantation can also be performed postoperatively to hide an incision, for hairline lowering, or for filling in the temporal recessions to produce hairline feminization.

Comparisons

What are the differences in hairline shape and distance between hairline to eyebrows between women and men?

The shape of the hairline can have significant effects on gender characterization. Multiple studies have been performed to characterize masculine and feminine hairline characteristics.(1-3) In general, the M-shaped hairline is more common in men and the rounded or rectangular hairline is more common in women.(1, 3)

The distance between the eyebrows and hairline is another characteristic with significant gender differences. A study by Nusbaum et al. found an average distance of 5.5cm between the mid-eyebrow to the frontal hairline midpoint for women.(4) Koo et al. found an average distance of 6.5cm in men.(5) These studies are limited due to comparisons between studies and differences that occur at different ages and with different ethnic backgrounds. They also do not take into account how the distances relate to remaining facial proportions. However, on average, women tend to have a lower frontal hairline than men.

Is the hairline or coronal approach better?

Neither approach is inherently better than the other. If your hairline has an appropriate shape and your forehead has an appropriate height, then a coronal incision is likely the better option since the scar can be hidden within your hair. If your forehead is the appropriate height (or close to it), but not the appropriate shape, a coronal incision with hair transplants may be best for you. If your hairline needs significant lowering, then a hairline incision may be the best option for hairline lowering.

What is the cost of hairline lowering (scalp advancement)?

Scalp advancement and the coronal incision are rarely performed in isolation. It is commonly performed in conjunction with reduction of the bones of the forehead when performed for transgender women. In this scenario, the cost of either procedure is minor compared to the total cost of the operation. Hairline lowering can be performed for cisgender women and is commonly performed in conjunction with a brow lift.

Hair transplantations either at the time of the operation or postoperatively does incur additional costs.

Recovery

How is the recovery after a scalp incision?

Recovery is usually tolerated well since scalp incisions generally are not significantly painful. Oftentimes, this procedure is performed in conjunction with other procedures. In those scenarios, the scalp incision is usually a minor concern.

How do I clean my hair after a scalp incision?

Cleaning instructions for your hair and scalp after a scalp incision is often variable and should be driven by your surgeon on an individual basis. If there are no hair transplants, the dressings can usually be taken off after about 24 hours. At that time, the hair can be cleaned with water and baby shampoo.

If staples and non-dissolving suture were used to close the scalp incision, hydrogen peroxide can be used to remove any crusted blood that has formed. If absorbable sutures such as chromic, plain gut, or fast gut were used, then hydrogen peroxide should be avoided. The use of hydrogen peroxide in these scenarios can prematurely break down these suture.(6)

When are the sutures and staples removed after a scalp incision?

If non-dissolving sutures or staples were placed at the time of surgery, these are usually removed at about 1 week after your operation. If absorbable sutures were placed, these are usually left to dissolve on their own. This usually takes a few weeks.

When can I dye my hair after the operation?

Assuming there are no complications with the healing process, there are no restrictions 1 month after surgery. This includes receiving a haircut or dying your hair.

Do I need to shave or cut my hair for these incisions?

There is no need to cut or shave your hair. The hair is braided prior to the operation to keep it clean and out of the way. At the end of the operation, the hair is washed to keep it clean. Sometimes there can be minor residual bleeding along the incision after the operation. That can get crusted into the hair. Shampoo or hydrogen peroxide work well to remove any crusting that occurs. Shorter hair can make postoperative care slightly easier, but it is not essential for surgery.

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Citations

1. Rodman R, Sturm AK. Hairline Restoration: Difference in Men and Woman-Length and Shape. Facial Plast Surg. 2018;34(2):155-8. Epub 2018/04/10. doi: 10.1055/s-0038-1636905. PubMed PMID: 29631285.

2. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg. 1991;15(2):141-7. Epub 1991/01/01. doi: 10.1007/BF02273847. PubMed PMID: 2035363.

3. Sirinturk S, Bagheri H, Govsa F, Pinar Y, Ozer MA. Study of frontal hairline patterns for natural design and restoration. Surg Radiol Anat. 2017;39(6):679-84. Epub 2016/11/11. doi: 10.1007/s00276-016-1771-1. PubMed PMID: 27830323. https://pubmed.ncbi.nlm.nih.gov/27830323/

4. Nusbaum BP, Fuentefria S. Naturally occurring female hairline patterns. Dermatol Surg. 2009;35(6):907-13. Epub 2009/04/29. doi: 10.1111/j.1524-4725.2009.01154.x. PubMed PMID: 19397668.

5. Koo SH, Chung HS, Yoon ES, Park SH. A new classification of male pattern baldness and a clinical study of the anterior hairline. Aesthetic Plast Surg. 2000;24(1):46-51. Epub 2000/04/01. doi: 10.1007/s002669910009. PubMed PMID: 10742469.

6. Athre RS, Park J, Leach JL. The effect of a hydrogen peroxide wound care regimen on tensile strength of suture. Arch Facial Plast Surg. 2007;9(4):281-4. Epub 2007/07/20. doi: 10.1001/archfaci.9.4.281. PubMed PMID: 17638764.