Hairline brow lift and forehead reduction

What it is

Two operations share one incision, placed at the front hairline (PMID 9915188):

• Hairline (pretrichial) brow lift. The brows are raised and excess forehead skin is removed without moving the scalp behind it. This keeps the hairline from moving back and shortens the forehead slightly, but does not lower the hairline (PMID 9915188, PMID 9915187).
• Hairline lowering (forehead reduction). The scalp is freed and pulled forward, then the bald skin in front of it is removed, so the hairline itself comes down (PMID 9915188, PMID 9915187).

A long forehead upsets the balance of the face and can make it look older (PMID 9915187). Surgeons judge it against the face divided into equal thirds, and choose the operation by how long the forehead is (PMID 19083505).

Where it came from

Coronal and endoscopic forehead lifts both raise the hairline, which is part of the reason many surgeons did not always recommend them (PMID 9915188). In 1991 McKinney measured faces to set a rule: when the brow-to-hairline distance in a woman is longer than about 5 cm, place the incision in front of the hairline (PMID 2035363). In 1997 Camirand tested hairline incisions side by side in the same patients and found that cutting across the hair follicles, so hair grows through the scar, gave the better scar (PMID 8982181).

In 1999 two papers used the hairline incision to shorten the forehead. Marten showed that adding a scalp advancement to the hairline incision lowers the hairline itself (PMID 9915188), and Guyuron anchored the advanced scalp to the skull through small bone tunnels (PMID 9915187). In 2008 Guyuron matched the operation to the forehead: an endoscopic lift for a slightly long forehead, a hairline lift for a moderately long one and a scalp advancement for a very long one (PMID 19083505). In 2014 Guyuron's group measured that the hairline stayed in place for 8 years or more after a hairline incision, while it receded after endoscopic lifts and in people with no forehead surgery (PMID 24374683).

Forehead reduction has since grown in popularity as a cosmetic operation on its own (PMID 33601981). Recent work refines how the scalp is held: absorbable implants (PMID 41117774), bone tunnels with a scalp flap that stretches more freely (PMID 41136698) and dissection that spares the forehead muscle and its sensory nerve (PMID 30688882).

Who it suits

• A lifelong high hairline. Hairline lowering suits people, typically women, with a high hairline since youth and no personal or family history of progressive hair loss (PMID 24017989).
• A stable hairline and a loose scalp. Candidates need a frontal hairline that is not receding, which excludes most men, and a scalp mobile enough to move forward (PMID 32312507).
• Low brows with a long forehead. For women with a long brow-to-hairline distance, the brow lift incision goes at the hairline (PMID 2035363); a moderately long forehead suits a hairline lift and a very long one a scalp advancement (PMID 19083505).
• A hairline already raised by earlier surgery. Incisions cut across the follicles avoid raising the hairline further and keep the temple tuft in place, which makes them useful in revisions (PMID 11176720).
• Facial feminization. A hairline brow lift with hairline advancement raises the brows and shortens the forehead in one operation (PMID 36580551), and can close bald areas at the temple corners (PMID 31800096).
• Possible hair disease. Surgeons screen for male pattern baldness and frontal fibrosing alopecia before forehead reduction, because both can affect the long-term result (PMID 40240586).
• Smokers. In Guyuron's series, temporary hair loss and most delayed healing occurred in smokers (PMID 9915187).

How it is done

The incision

The incision follows the front hairline and is cut across the hair follicles, so hair grows through and in front of the scar; in a blinded side-by-side test this gave the better scar in nearly every patient (PMID 8982181). An irregular line along the hairline is used to make the scar harder to see (PMID 19289679).

Brow lift through the hairline

The surgeon raises the brows by freeing the forehead either just under the skin or under the deeper galea layer, then removes the extra forehead skin (PMID 9915187). Working in the deeper layer improves the blood supply to the forehead skin (PMID 25457833). Combined with an upper eyelid lift, this lift raises the outer brow more than the inner brow (PMID 27398009).

Hairline lowering

The scalp is freed back to the back of the head, relaxing cuts are made in the galea, and the whole scalp is moved forward (PMID 9915187). The galea is then fixed to the skull so the scalp cannot slide back: the stiffer the scalp, the more relaxing cuts and rows of bone tunnels it needs (PMID 9915187). The bald forehead skin in front of the new hairline is removed and the edges are sewn carefully (PMID 9915187).

• Bone tunnels. Stitches pass through small channels in the outer skull; the result was immediate and unchanged at 12 months (PMID 30380006).
• Absorbable implant (Endotine). A small tined implant holds the scalp while it heals; the lowered hairline held past a year (PMID 41117774).
• Stretching the flap. Cuts through the periosteum and galea and two rows of advancement stitches allow a tension-free closure (PMID 41136698).
• Sparing the nerve. A multiplane technique keeps the forehead muscle and the supraorbital nerve intact (PMID 30688882).

Hair transplantation instead

A hair transplant can lower the hairline with grafts instead of moving the scalp; patients rated the result highly (PMID 30675719). Surgical lowering gives full hair density at once (PMID 32312507).

Results and how long they last

Forehead reduction shortens the forehead by about 1.6 cm in pooled data (PMID 33601981), and in one large series by as much as 5 cm (PMID 41219546). The upper third of the face came close to equal with the middle third after surgery (PMID 34305024). Patient satisfaction in pooled data was nearly universal (PMID 41663770).

The change shows immediately and holds: forehead length at 12 months matched the first month (PMID 30380006). Part of the shortening is lost over time; in long-term follow-up the forehead lengthened again by about 2 mm (PMID 33683382).

For the brows, hairline and endoscopic lifts held their lift equally at about 6 years (PMID 35653546). An endoscopic lift raised the brow more at first, and the two matched in the long run (PMID 41239801). Lifts with the incision in front of or behind the hairline showed no long-term difference (PMID 40788666). The hairline itself stayed stable for 8 years or more after a hairline incision, with no gap opening between scar and hair (PMID 24374683).

Risks and how surgeons lower them

• Scalp numbness. Nearly everyone has temporary numbness of the scalp (PMID 41663770). After open brow lifts, numbness stayed permanent in about 1 in 80 (PMID 19153287). Sparing the supraorbital nerve limited numbness to the front center of the scalp (PMID 30688882).
• Inflamed follicles (folliculitis). About 1 in 4 patients develop it along the incision (PMID 41663770).
• Hair shedding and hair loss. Temporary shedding is common after forehead reduction (PMID 40240586); after implant fixation it cleared with minoxidil in every case (PMID 41117774). Hair loss at the incision is rare (0.7%) (PMID 41663770). When the forehead was lifted just under the skin through a hairline incision, hair loss occurred in about 1 in 12 (PMID 23388642); working in the deeper plane improves blood supply to the flap (PMID 25457833).
• A visible or wide scar. Scarring problems occurred in about 1 in 18 in pooled data (PMID 41663770). Cutting the incision across the follicles improves it (PMID 8982181).
• Revision. Hairline brow lifts had the highest revision rate of any brow lift type, 7.4% (PMID 30534495). After forehead reduction, about 1 in 75 had revision surgery (PMID 41663770).
• Fluid, wound and skin problems. Seroma occurred in about 2 in 100 (PMID 41663770). Skin loss was reported in about 2 in 100 lifts done just under the skin (PMID 23388642), and delayed healing at the temple occurred mostly in smokers (PMID 9915187).
• Fixation devices. One surgeon's implant series reported complications in about 1 in 4, most often temporary hair loss (PMID 41117774).

Overall complication rates are low: 1% or less in one pooled analysis (PMID 33601981) and about 6 in 100 in a larger, later one (PMID 41663770).

Recovery

• Scalp numbness is expected; it resolved by 2 months in one series (PMID 38151038) and within 6 months in another (PMID 41136698).
• The new forehead length is visible right after surgery (PMID 30380006).
• Shedding after surgery is temporary, and minoxidil cleared it in one series (PMID 41117774).
• Smokers who keep smoking after surgery risk hair loss and slow healing (PMID 9915187).
• The hairline scar stays at the hairline years later, with no gap of bare skin between scar and hair (PMID 24374683).

With a facelift

• A previous facelift is one of the reasons to consider a forehead lift, and the incision is chosen by the brow-to-hairline distance (PMID 2035363).
• Cutting across the follicles improves hairline scars in facelifts as well as brow lifts (PMID 8982181).
• Temple hair grows out at a shallow angle, so a bevelled temple incision in a facelift allows hair to grow through and in front of the scar (PMID 17440370).
• Incisions across the follicles at the forehead and temple are useful when an earlier operation raised the hairline or temple tuft (PMID 11176720).
• A hairline brow lift done with an upper eyelid lift gives the most lift at the outer brow (PMID 27398009).

Questions to ask a surgeon

• Do I need a brow lift, a hairline lowering, or both? (PMID 9915188)
• Is my hairline stable, and have you checked me for pattern hair loss or frontal fibrosing alopecia? (PMID 40240586)
• How mobile is my scalp, and how far can my hairline come down? (PMID 32312507)
• How will you hold the scalp in place: bone tunnels or an implant? (PMID 41117774)
• Will you cut the incision across the hair follicles so hair grows through the scar? (PMID 8982181)
• How long will my scalp be numb, and how often do your patients get folliculitis? (PMID 41663770)
• How often do your hairline lifts need a revision? (PMID 30534495)
• Would a hair transplant suit me better? (PMID 30675719)

Open questions

• Minor problems are common (folliculitis, temporary numbness) even though satisfaction is nearly universal (PMID 41663770).
• How much of the forehead shortening is lost over the long term (PMID 33683382).
• Which fixation is better: absorbable implants (PMID 41117774) or bone tunnels (PMID 30380006, PMID 41136698).
• Incision extensions along the temples gained more advancement in cadavers only (PMID 42576061).
• Choosing candidates when hair disease may progress, and whether large reductions raise the need for scar revision (PMID 40240586).
• Hairline or endoscopic lift for a high forehead: long-term brow height and complications are similar, so hairline position and forehead length guide the choice (PMID 41239801).
• Measured outcomes in facial feminization (PMID 36580551).

Terms

• Pretrichial incision: incision just in front of the hairline (PMID 9915188).
• Trichophytic incision: incision beveled across hair follicles so hair grows through the scar (PMID 8982181).
• Hairline lowering / forehead reduction: moving the hairline down by advancing the scalp (PMID 24017989).
• Scalp advancement flap: scalp freed from the skull and pulled forward (PMID 9915188).
• Galea and galeotomy: the fibrous scalp layer, and relaxation cuts in it to gain advancement (PMID 9915187).
• Bone tunnel fixation: sutures passed through small channels in the outer skull to hold the scalp (PMID 30380006).
• Endotine: absorbable implant with tines that holds scalp tissue while it heals (PMID 41117774).
• Effluvium: temporary hair shedding after surgery (PMID 40240586).
• Folliculitis: inflamed hair follicles along the incision (PMID 41663770).
• Trichion: midpoint of the front hairline, used to measure forehead length (PMID 34305024).

Papers