This procedure is for women and men who were born with a very high hairline and a long forehead, sometimes jokingly referred to as a “fivehead.” This procedure lowers the hairline, which creates a shorter forehead and a more balanced appearance to the face. It reduces the vertical height of the forehead and can be combined with a browlift if desired. To advance the hairline, an incision is made right at the hairline. Dissection is performed in the plane under the scalp all the way to the back of the head. Once all of the scalp tissue is loosened, the whole scalp is brought forward. Extra skin from the forehead is removed, and very careful stitches are placed to seal the hairline to the new, lower forehead.
Another procedure that Dr. Rodman performs in conjunction with the above procedures is a brow lift.
In a brow lift, Dr. Rodman raises the eyebrows slightly above the orbital rim and creates a gentle curve. This takes away the heavy, tired, or saggy appearance and creates a refreshed, soft, and feminine appearance. She takes care to create a look where patients still appear natural. The goal is for patients to still appear as themselves, just a rested and refreshed version of themselves.
What is the downtime with this procedure?
Everyone’s healing and pain threshold is different, but the short answer is this isn’t a terribly painful procedure. Patients need about one week off of work and three to four weeks away from high intensity exercise or lifting weights. For the first few days after surgery, patients will have headache and tightness, but most patients report the pain to be tolerable. Patients will feel well after one week, but need to continue scar care up to one year after surgery. There are various products such as silicone gel and scar strips available in Dr. Rodman’s office that can help soften the appearance of the scar as it heals.
But what about the scar?
The most common question about hairline advancement, or forehead reduction, is about the scar. There is a large scar at the hairline after a hairline advancement. At first mention, the idea of a scar that stretches the entire length of the hairline may seem like too much! The good news is, even though the scar is long, it hides very well. The scar is placed right in the transition between the forehead and hair. When we look at other people, we are used to seeing a change in the texture and color of skin to the hair. Putting a small scar in this transition works like an optical illusion, and it is nearly invisible.
Placement of the scar is important, but there is another trick Dr, Rodman uses to hide the scar. This is called a trichophytic incision. When the incision is made, the blade is held at an angle. The cut through the forehead skin is diagonal, instead of being straight down from skin to bone. This leave the follicles of the first few hairs in place. Although those hairs get cut off in the surgery, the follicle is still present and can grow hair in the future. Once the excess skin is trimmed, the new forehead skin is brought up, cut at the opposite angle, and draped over the follicles. With time, these follicles will grow hairs again. The hairs that they grow will grow through the scar, making the scar very hard to see.
The second surgical trick Dr. Rodman uses is to close the scalp in several layers. She pulls the hair forward and lifts the brow (when desired) and secures the position by sewing the periosteum of these two flaps together. This is a very strong layer of tissue and helps secure the position. She then puts long term dissolving sutures into the galea, which is another strong layer or tissue. These two layers are what holds the wound edges together and gives strength to the closure. These stitches do dissolve over time, but last long enough for the scar to heal well. The goal with Dr. Rodman’s layered closure is to have no tension on the incision. By using two strong layers underneath the skin first, the skin edges come together perfectly. The top layer of stitches in the skin is simply to bring a perfect seal to the top layer. These stitches come out at about one week. It is fine for these stitches to come out at this point, because there are still at least two layers of stitches underneath that will hold the incision together for many weeks to come while it is still healing.
Some patients ask about staples. No! We do not use staples in the face! The words “face staples” are like profanity in our office. While we may use them for a portion of the incision that is entirely in the hair, staples are never used in the face. Staples can cause tract marks (think Frankenstein) and do not heal as well as removable sutures. Dr. Rodman feels that if you are going to invest in a surgery that improves your appearance, you deserve for every detail to be the best it possibly can be.
In addition to surgical techniques, patients must perform diligent scar care. For the first 2-3 weeks, Dr. Rodman recommends that patients keep the incision covered with Vaseline or Aquaphor. Some patients chose to wear a headband to cover the incision and to keep the ointment on at first. Any plain soft cloth headband will be fine, as long you can wash it after each use. The headband is also a good trick to hide the incision for patients who have to go back to work quickly after the procedure. After the incision is totally sealed and there are no red spots, patients switch from Vaseline to scar gel. Face Forward sells Silagen scar gel, which also has sunscreen in it. The Silagen is nice because it seals in moisture and helps the scar to soften, but does not feel greasy. Patients can put make up on over it if they desire. Sunscreen is a MUST for the first year after surgery. If the scar gets sunburned and turns red, it tends to stay an angry red. Keeping the scar covered with sunscreen and/or a hat is crucial in the first year of healing.
As the scar heals, it will go through many phases. It takes a full year for the scar to heal. The first week it has stitches. After one week those stitches come out and it may look a bit raw for another week. By one month, much of the scar has sealed and healed and is usually looking good. Between months 2-4 the scar begins to look red. It may look worse than it did a month before. That is totally normal, and actually a good sign! The redness is caused by new blood vessels growing in, which heal and remodel the scar. If you were to look with a magnifying glass, you can see hundreds of tiny blood vessels growing into the scar tissue. From far away the blood vessels just makes the scar look red. This process is called “neovascularization” and means everything is healing well. By month 6 the redness fades and the scar starts to turn white. It will continue to contract (become smaller) and flatten. The changes become less at this point, but the scar will continue to remodel and improve.
Here are some photos to help you get an idea of what to expect!