How to Make a Long Forehead
More Aesthetic
Bahman Guyuron, MD; and David J. Rowe, MD
Background: Aesthetic analysis of the face is best accomplished by dividing the face into equal thirds. A long
forehead may lend the appearance of a less attractive, disproportionate, and senescent face.
Objective: To provide data regarding options for surgical correction of the long forehead.
Methods: Patients complaining of excess forehead length were divided into 3 groups on the basis of forehead length in relation to other facial proportions. Patients with mild elongation underwent an endoscopic
forehead lift, those with moderate elongation underwent an open forehead lift, and those with severe forehead elongation underwent open forehead shortening.
Results: A total of 755 patients were evaluated, including 702 women and 53 men undergoing forehead surgery since 1998. Follow-up ranged from 12 months to 8 years. Four hundred thirty-eight patients underwent
endoscopic forehead lift for mild forehead elongation, 297 patients underwent pretrichial forehead lift for
moderate elongation, and 20 patients underwent major scalp advancement for severe forehead elongation.
Successful forehead rejuvenation was achieved in all groups. Complications were minor and included alopecia and delayed wound healing.
Conclusions: An optimally proportioned forehead may be achieved by use of a variety of elective operations
on the basis of severity of forehead excess and geared to reducing forehead length. (Aesthetic Surg J
2008;28:46–50.)
he aesthetic balance of facial proportions is paramount to the aesthetic facial norms. Attractiveness
is often defined as a proportionality of the major
aesthetic units.1 In the profile view of the face, the
artist’s cannon of “equal facial thirds” divides the face
into 3 equal parts: the lower segment (measured from
menton to the subnasale), the nasal segment (measured
from subnasale to glabella), and the forehead segment
(measured from the glabella to the hairline).2 Farkas and
Kolar3 have shown in their anthropometric evaluations
that in the forehead, lower hairlines and a slightly smaller upper facial third is more attractive. Conversely, a
forehead that is longer than the other facial segments is
seen as less attractive and also viewed as senescent.4
Elongation of the forehead may be the consequence
of androgenic hair loss or trauma, or it may be iatrogenic, the causality of a coronal forehead lift. Regardless
of cause, forehead elongation can be divided into mild,
moderate, and severe. Previous reports have described
techniques used to address each of these forehead discrepancies. This study retrospectively investigates the
efficacy of these techniques in achieving an aesthetically
appealing forehead.
T
Dr. Guyuron is Chair and Dr. Rowe is Assistant Professor,
Department of Plastic Surgery, University Hospitals of Cleveland
and Case Western University, Cleveland, Ohio.
46 • Volume 28 • Number 1 • January/February 2008
PATIENT SELECTION
Patients were assessed by use of soft tissue cephalometric analysis, and the length of the forehead relative to
the face was analyzed. A detailed history was obtained,
including previous surgery to the scalp and forehead,
history of smoking, diseases of the hair or scalp, and
any history of hair loss.
Patients were stratified into 1 of 3 categories, depending
on the amount of forehead elongation and the procedure
being used. For patients with a minimal to mild amount of
forehead elongation (less than 5 mm), a standard endoscopic forehead rejuvenation was performed. Patients
exhibiting a moderate amount of forehead elongation were
subjected to forehead rejuvenation using an anterior hairline incision and subcutaneous dissection for nonsmokers/subgaleal dissection for smokers. In patients considered
to have significant forehead elongation, extending greater
than 10 mm beyond what would be considered aesthetically pleasing, a posterior scalp advancement was performed.
SURGICAL TECHNIQUE
Mild Forehead Elongation
Mild forehead elongation is usually associated with slight
to moderate wrinkling and possible brow ptosis, in addition
to forehead lengthening less than 5 mm. Endoscopic
Aesthetic Surgery Journal
Figure 1. Incision for open techniques. The pretrichial incision is
curvilinear and performed in a beveled fashion.
Figure 2. Coronal galeal scoring. Monopolar cautery is used, taking
care not to injure hair follicles. Each scoring will release the scalp
approximately 1.5 to 2.0 cm in length.
release of the eyebrow depressors and arcus marginalis will
cause a slight elevation of the eyebrows, the providing the
appearance of a shortened forehead. The senior author’s
(BG) technique for endoscopic forehead rejuvenation has
been previously published.5-7 Briefly, 5 radial scalp incisions were made. The midline incision was marked approximately 0.5 cm behind the hairline. The next incisions were
marked as the vector of eyebrow elevation, usually 6.5 to 7
cm lateral to the midline incision. These markings were
approximately 1 cm behind the hairline. The final 2 markings were made approximately 3 cm lateral to the second
incisions. The incisions, which were typically 1.2 to 1.5 cm
in length, need to be slightly extended in men or in patients
with thicker skin. Subperiosteal endoscopic dissection was
initially performed to the level of the supraorbital rim. The
dissection was continued laterally to the level of the lateral
orbital rim, the zygomaticofrontal suture, and zygomatic
arch to release the orbital retaining ligament. Hemostasis
was obtained with a malleable suction electrocautery
(Valley Lab, Boulder, CO). The sentinel vein may also be
cauterized, taking care to adequately identify the vein from
its investing fascia close to the facial nerve. After dissection, the periosteum and arcus marginalis were released at
the lateral orbital rim and continuing to the supraorbital
area. The supraorbital nerves were exposed and protected.
The periosteum was preserved in the midline in the glabellar region, unless the medial eyebrows were positioned
extremely low. The preservation of the periosteum in the
glabellar region was done to prevent excessive elevation of
the medial brow and the resultant “surprised” look.
The glabellar musculature, including the corrugator
supercilii, depressor supercilii, and procerus were then
resected. Contrary to other reports, the senior author
resected the glabellar musculature as completely as possible.8,9 This was done to virtually eliminate the risk of
recurrent glabellar lines. The supraorbital and supratrochlear nerves were identified and preserved, thus leaving the nerves in a skeletonized fashion. Once the
muscles were resected, the subcutaneous fat was visual-
ized. As previously reported, a piece of fat roughly equal
to the volume of the resected muscle was harvested
through a small incision in the deep temporal fascia
above the medial zygomatic arch.6 This was performed
with the sharp end of a curved periosteal elevator
(Snowden-Pencer, Tucker, GA). If concomitant procedures
are being performed, fat from other sites may be used.
Brow suspension was performed laterally with fascial
suspension only. However, if the arch shape needs to be
altered or there was significant brow asymmetry, bone fixation through the intermediate lateral incision may be
used. A 3-0 PDS suture was used for the fascial suspension at the lateral-most incision. The suture was passed
from the caudal end of the incision at the level of the
superficial temporal fascia. Skin retractors were then
placed in a cephalic position while the scalp was pulled in
a cephalic-lateral direction. The suture was then placed in
the deep temporal fascia at this point, effectively attaching
the superficial and deep temporal fascia at this level.
A closed suction drain was placed in the lateral-most
incision and traversed the length of the forehead incisions. A combination of 5-0 Vicryl (Ethicon, Inc.
Somerville NJ) and 5-0 plain catgut were used to reapproximate the scalp. The drain was typically removed
after 2 days. After surgery all patients were placed on a
methylprednisolone taper regimen (Medrol dose pack;
Pharmacia & Upjohn, Pepack, NJ).
How to Make a Long Forehead More Aesthetic
Moderate Forehead Elongation
In cases determined to have moderate forehead elongation (5 to 10 mm), an open forehead technique was used.
In smokers, the dissection was carried in the subgaleal
plane, whereas in nonsmokers, dissection was in a subcutaneous plane. The pretrichial incision was performed
in a curvilinear beveled fashion (Figure 1).10 Dissection
was then carried in the subcutaneous plane caudal to the
last horizontal forehead crease. The dissection was then
carried deep to the frontalis on its medial border until the
corrugator muscles were identified. The corrugator musVolume 28 • Number 1 • January/February 2008 • 47
Figure 3. Bone tunneling. Tunnels are made with a 5-mm burr, creating
2 holes approximately 3 to 4 mm apart, at opposing 45-degree
angles, such that the holes meet at a depth of 3 to 4 mm.
Figure 4. Suture fixation with 3-0 PDS. The galea is advanced and
fixated in 3 separate sites on each row.
Figure 5. Final row of fixation. Fixation is close to the level of the
incision. This eliminates unnecessary tension at the suture line.
Figure 6. Forehead skin is excised to the level of the advanced scalp.
No unnecessary tension is on the incision line.
cles were subsequently removed, taking care to identify
and protect the supratrochlear and supraorbital nerves.
The resultant soft tissue defect left by the corrugator
removal was filled with fat graft from other dissection
sites or from pericranium if no fat was available. The
skin was then redraped under no tension and the excess
tissue excised. A suction drain was placed in the cavity
prior to closure. The skin was then approximated with
running, locking 6-0 fast-absorbable plain catgut.
Posterior scalp advancement may be performed with
the patient under intravenous sedation and circumferential scalp infiltration with lidocaine containing 1:100,000
epinephrine. The dissection was continued through the
galea to the level of the periosteum. The scalp was then
elevated in the supraperiosteal plane posteriorly to the
level of the occipital notch and laterally to the ear.
Relaxation incisions were then made in the galea in a
coronal-type plane (Figure 2). Depending on the amount
of advancement needed and the pliability of the scalp,
multiple relaxation incisions may be performed.
Generally, each relaxation incision will provide 1.5 to 2.0
cm of scalp advancement. Meticulous hemostasis was
obtained at the galeal level, taking care to avoid injury to
the hair follicles. Once optimal scalp advancement was
obtained, bone tunnels were made at the corresponding
scalp level. A 5-mm burr was used to create 2 holes
approximately 3 to 4 mm apart, at opposing 45-degree
angles, such that the holes met at a depth of 3 to 4 mm
(Figure 3). Fixation was achieved with a 3-0 PDS suture
Severe Forehead Elongation
In cases of severe forehead elongation (greater than 10
mm of elongation), a combination of forehead lift and
posterior scalp advancement was used. Before the open
forehead advancement as described above, the new position of the hairline was marked with a 25-gauge needle
down to the level of the periosteum. If the subgaleal
approach is performed, such as in patients with a positive smoking history, the dissection is continued to the
level of the supraorbital rims.
48 • Volume 28 • Number 1 • January/February 2008
Aesthetic Surgery Journal
A
B
Figure 7. A, Preoperative photo of patient with severe elongation of the forehead. B, Results 12 months after surgery. Note lack of visibility of the
forehead scar.
A
B
Figure 8. Patient demonstrates postoperative alopecia. A, View 4
weeks after surgery. B, After excision of alopecia.
that was passed through the galeal fascia and its corresponding bone tunnel (Figure 4). The galea was
advanced and fixated in 3 separate sites on each row.
The number of rows used was determined by the suppleness of the scalp and the amount of advancement
obtained. The final row of fixation should be close to the
level of the incision. This eliminates unnecessary tension
at the suture line (Figure 5).
The residual non-hair-bearing forehead, usually ranging from 2 to 5 cm, was removed up to the level of the
advanced scalp (Figure 6). The scalp was then repaired
with 5-0 Vicryl and 6-0 plain catgut. The incision line
was treated with CO2 laser and a liquid silicone dressing.
After surgery, the patients were instructed not to use a
hairdryer for 10 days to 2 weeks and not to color their
hair for about 3 weeks.
RESULTS
Experience with these procedures included 755 total
patients since 1998. There were a total of 702 women
and 53 men. Follow-up ranged from 12 months to
8 years. A total of 438 underwent endoscopic forehead
lift for mild forehead elongation, 297 patients underwent
How to Make a Long Forehead More Aesthetic
pretrichial forehead lift for moderate elongation, and
20 patients underwent major scalp advancement for
severe forehead elongation (Figure 7).
Complications of these procedures were minimal. No
hematoma or infection was noted. No permanent paresthesias was encountered in any group. In the major
scalp advancement group, 3 patients had experienced
some degree of alopecia, one of which was temporary.
One patient exhibiting hair loss was treated with excision of the alopecia region (Figure 8). The causality of
this significant alopecia is unknown; however, it may be
a consequence of excessive tension on the closure or
decrease in vascularity of the scalp. Six patients who
underwent pretrichial forehead lift and one who underwent forehead lift and scalp advancement had delayed
healing of the temporal region. Only 2 of these patients
required subsequent successful scar revisions.
DISCUSSION
A high forehead is recognized as a sign of senescence and
also detracts from the proportionality and aesthetic characteristics of the face. Therefore the ability to lower the
hairline may make the patient appear not only younger,
but also more attractive.11 Patient selection includes a
careful analysis of the upper third of the face. This evaluation will reveal the severity of the elongation. A mild
deformity, which constitutes minimal forehead elongation, mild to moderate wrinkling, and eyebrow ptosis, is
best corrected with an endoscopic forehead lift. Patients
who exhibit moderate forehead elongation are best treated
with the use of a pretrichial open forehead lift. Severe
forehead elongation is treated with scalp advancement via
an anterior hairline incision. This subgaleal dissection is
continued to the occiput. The flap is subsequently secured
to the cranium with anchoring sutures.
The techniques described for mild and moderate forehead elongation may result in forehead shortening; however, they will not change the location of the hairline.12
Thus the distance between the eyebrows and the hairline
will be the only effective change. The only technique
described here that will elicit an alteration in the location of the hairline is the scalp advancement.
Volume 28 • Number 1 • January/February 2008 • 49
The cause of forehead elongation may also be a result
of androgenic hair loss or trauma or may be iatrogenic
after coronal forehead lift. In the case of male pattern
baldness, men with stable Norwood classification II or III
may be reasonable candidates for forehead shortening.13
One must be cognizant of progressive hair loss and the
possibility of scar visibility. In any instance, patients
must be evaluated for quality of hair and scalp mobility.
Patients who exhibit poor mobility of the scalp or have
had previous scalp surgery may not achieve optimal
results and thus may not be ideal candidates for forehead
shortening. In this study, several patients exhibited transient or permanent alopecia. To decrease the possibility
of hair loss, tension on the scalp should be relieved by
placing multiple rows of suture anchors, effectively
diminishing the tension on any one area. Also, care must
be taken when scoring the galea not to injure the hair follicles immediately superficial to the galea.
Previous reports have described techniques used to
address each of these forehead discrepancies. This study
retrospectively investigates the efficacy of these techniques in achieving an aesthetically appealing forehead. ◗
DISCLOSURES
The authors have no disclosures with respect to this article.
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Follicular anatomy of the anterior temporal hairline and implications
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11. Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg
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Accepted for publication Sept. 21, 2007.
Reprint requests: Bahman Guyuron, MD, 29017 Cedar Rd, Lyndhurst, OH
44124.
Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$34.00
doi:10.1016.j.asj.2007.10.008
50 • Volume 28 • Number 1 • January/February 2008
Aesthetic Surgery Journal