TY - JOUR
AU - Kim, Young, Seok
AB - Abstract Background People with a wide forehead often look older. Hairline lowering surgery is a good treatment option, which is generally performed utilizing Endotine. Objectives We describe our hairline lowering surgical technique involving bone tunneling without Endotine, a method designed to produce comparable outcomes with fewer side effects. We evaluated the effectiveness and safety of our technique. Methods Charts of 91 patients who underwent hairline lowering surgery without Endotine were reviewed retrospectively. We utilized standardized preoperative and postoperative photographs to measure the proportions of 3 face parts and the length of the forehead. We also determined changes in forehead length at various times after surgery, occurrence of postoperative complications, and overall patient satisfaction with their surgical results. Results Of the 91 patients, 80 were female and the mean age was 28.67 ± 7.15 years. Preoperatively, the mean forehead length was 8.09 ± 0.69 cm and ratio of facial part lengths was 1.08:1:0.99 (cranial to caudal). The hairline was advanced 18.37 ± 2.90 mm. One month postoperatively, the mean forehead length was 6.57 ± 0.52 cm and facial parts ratio was 1:1:0.99. Compared with preoperatively, forehead length was significantly reduced at 1, 3, 6, and 12 months postoperatively. Forehead length was not significantly different at 1 and 12 months postoperatively. All patients were satisfied or very satisfied with their overall surgical results. Conclusions Hairline lowering surgery with bone tunneling was effective and safe, and patients were satisfied with the results. The effects appeared immediately following surgery and were sustained over time. Level of Evidence: 4 The face is customarily considered more important than any other body part because it represents a major aspect of a person’s identity. Therefore, different methods have been developed to enhance facial features, along with various attempts to establish standards for beauty. Dividing the face into parts and balancing these parts to achieve a desirable ratio is one of the most common ways to define beauty. Aesthetically pleasing faces are those that conform to a balanced ratio.1 One of the most frequently used tools for evaluation is the artist’s canon of “equal facial thirds.”2 In this method, the face is divided it into 3 parts—the forehead, nasal segment, and lower segment—in profile view. The face is considered desirable when the ratio of these 3 parts is equal.2-4 Nevertheless, various researchers have argued that a face is more attractive when the upper part is relatively small compared with the middle or lower part.5 A smaller upper face can be achieved by lowering the hairline. There are many causes for a high hairline, such as genetics, androgenic hair loss, trauma, and iatrogenic etiologies.6 A person can appear less attractive and older if the forehead is long and wide, compared with other facial parts. In addition, a large forehead in females may produce a masculine appearance.7 Generally, women who opt for plastic surgery prefer a Western look, with a small face and large, distinctive facial features.8 However, people with a long forehead because of a high hairline opt for surgery because it makes their face appear unbalanced and large. A new hairstyle, a wig, make-up, and tattoos can temporarily decrease forehead size. However, none of these methods produce fundamental, permanent changes. Surgical methods of reducing a long forehead include hair transplantation and hairline lowering surgery. In this report, we describe a hairline lowering technique using bone tunneling without Endotine (MicroAire, Charlottesville, VA). We also evaluate the procedure’s effectiveness by measuring the reduced forehead length and its safety by reviewing postoperative complications. METHODS We retrospectively analyzed the medical records of patients who underwent hairline lowering surgery using bone tunneling without Endotine from March 2016 to November 2016 at our clinic. This study was approved by Yonsei University Gangnam Severance Hospital, Institutional Review Board (3-2018-0048). And informed consent was provided by patients. Preoperative evaluations, including a physical examination and review of the patients’ medical history, were completed. Patients with a high hairline, good scalp mobility, good scalp hair, and no scalp disease were included. We recorded whether the patient underwent previous hair transplantation, semipermanent tattooing, or procedures through a coronal approach. Individuals with previous procedures via a coronal approach and those with androgenic alopecia were excluded from hairline lowering surgery. A total of 91 patients were included in this study. The patients returned to the clinic for follow-up at 1, 3, 6, 12, and 24 months postoperatively. At these visits, their clinical progress was evaluated, and photographs were obtained using a digital camera (Canon 600D; Canon Corporation, Tokyo, Japan). The photographs were taken in a standardized manner by physicians, ensuring that the Frankfort horizontal plane was respected. They were analyzed using the ImageJ program. To obtain objective values for hairline position and forehead length, we evaluated the left and right six-quarter and crown view photographs. We measured the following in an absolute vertical orientation: facial height (trichion to menton), forehead segment (glabella to trichion), nasal segment (glabella to subnasale), and lower segment (subnasale to menton). Because the forehead has a curved linear shape, we measured the forehead length in the mid-frontal line. Clinical evaluation preoperatively included examination of the following: hair direction, frontotemporal points, recession of the anterior hairline, and laxity of the scalp. Suitable scalp laxity was determined by placing a thumb on the anterior hairline, pushing the scalp down as much as possible, and then measuring the distance the scalp moved from the hairline (Figure 1). After surgery, clinical evaluation included assessment of the amount of forehead reduction and occurrence of complications. Forehead reduction was measured by changes in forehead length in the mid-frontal line on preoperative and postoperative photographs. The patients also completed a satisfaction survey in which they were asked to rate their overall level of satisfaction on 5-point scale from 1 (very dissatisfied) to 5 (very satisfied).9 Figure 1. View largeDownload slide Measurement of scalp laxity demonstrated on this 30-year-old female patient. (A) Positioning a ruler beside the anterior hairline. (B) Pushing the scalp down as much as possible with the thumb. Figure 1. View largeDownload slide Measurement of scalp laxity demonstrated on this 30-year-old female patient. (A) Positioning a ruler beside the anterior hairline. (B) Pushing the scalp down as much as possible with the thumb. Operative Technique The operative procedure is shown in Figures 2 and 3. The patient is first placed in the supine position and administered intravenous sedation, supratrochlear and supraorbital nerve blocks, and additional local anesthesia infiltration in the operative field. The surgery begins with an irregular trichophytic incision along the anterior hairline. Next, a width determined by the degree of scalp laxity—which is decided during the preoperative evaluation—is marked from the incision line at the anterior hairline. Then, a line parallel to the hairline incision is drawn laterally, ending at the temporal recession on both sides of the head. To prevent transecting the posterior branch of the superficial temporal artery, the incision should not be too long. Care must be taken to perform the incision in line with the beveling of the scalp and the trichophytic incision. The hair follicles are preserved by a trichophytic incision along the preoperatively marked line, which allows the scar to remain hidden amidst hair growth. Figure 2. View largeDownload slide Schematic representation of the overall operative procedure. (A) Design, (B) excision, (C) subgaleal dissection, (D) bone tunnel, (E) scalp advancement, and (F) suturing. Figure 2. View largeDownload slide Schematic representation of the overall operative procedure. (A) Design, (B) excision, (C) subgaleal dissection, (D) bone tunnel, (E) scalp advancement, and (F) suturing. Figure 3. View largeDownload slide Steps in hairline lowering surgery using multiple bone tunnels demonstrated on this 30-year-old female patient. (A) Bone tunnels, as shown after tissue excision. (B) Scalp advancement and fixation using 2-0 polydioxanone. (C) Subcutaneous suturing, and (D) skin suturing. Figure 3. View largeDownload slide Steps in hairline lowering surgery using multiple bone tunnels demonstrated on this 30-year-old female patient. (A) Bone tunnels, as shown after tissue excision. (B) Scalp advancement and fixation using 2-0 polydioxanone. (C) Subcutaneous suturing, and (D) skin suturing. Beveling begins 2 to 3 hairs from the transition point, between lanugo and thicker, dense hair. Next, the full skin layer is cut, and full-layer excision is performed, sparing the neurovascular bundle. Bloodless dissection is then performed through the subgaleal plane. The tissues are resected and the periosteum removed for bone tunnels. Bone tunnels are created in the midline and along bilateral pupil lines using an electric drill and 4 to 6 V-shapes. After a passing 2-0 polydioxanone (PDS) suture through the galeal layer of the scalp flap, the flap is advanced as much as possible before the suture is tied. The skin is meticulously approximated using 4-0 PDS subcutaneous sutures, followed by 6-0 nylon intermittent and running skin sutures. The suturing must be thorough and consider the beveling so the forehead skin will cover the denuded hair follicles of the trichophytic incision. Platelet-rich plasma is injected into the area around the skin incision immediately after skin closure, and a compressive dressing is applied to reduce swelling and telogen effluvium. Postoperative Care Patients were asked to return to the clinic the day after surgery for dressing removal and ointment application. After this, they were permitted to resume usual daily activities. The stiches were removed 7 to 10 days postoperatively. Statistical Analysis Statistical analysis was performed by means of SPSS Version 18.0 statistical software (SPSS, Inc., Chicago, IL). Categorical variables are characterized using frequency and percentage, and continuous variables are characterized as mean and standard deviation or as median and range. Quantitative variables at different times were compared by means of the paired t test. Statistical significance was defined as P < 0.05. RESULTS Ninety-one patients were included in this study: 80 women and 11 men. Their mean age was 28.67 ± 7.15 years (range, 18-47 years), and the median follow-up period was 24.2 months (range, 20-29 months). Four patients with previous forehead augmentation employing silicone implants for aesthetic purpose were included. Before surgery, the ratio of the mean length of the 3 facial segments was 1.08:1:0.98 (cranial to caudal), and the mean forehead length was 8.09 ± 0.69 cm. The mean advancement distance (marked before surgery) was 18.37 ± 2.90 mm. The mean facial segment ratio at 1 month after surgery was 1:1:0.98. The mean forehead length was 6.57 ± 0.52 cm, 6.61 ± 0.52 cm, 6.53 ± 0.43 cm, and 6.50 ± 0.41 at 1, 3, 6, and 12 months after surgery, respectively (Table 1; Figure 4). Table 1. Forehead Length Preoperatively and Postoperatively Mean ± SD (cm) Compared with preoperative Compared with postoperative 1 month Differences 95% CI P value Differences 95% CI P value Preoperative 8.08 ± 0.63 — — — — — — Postoperative1 month 6.57 ± 0.52 1.502 1.401, 1.603 <0.001a — — — Postoperative3 months 6.61 ± 0.52 1.491 1.360, 1.624 <0.001a 0.016 0.003, 0.028 0.018b Postoperative6 months 6.53 ± 0.43 1.477 1.329, 1.626 <0.001a 0.011 −0.002, 0.025 0.103b Postoperative12 months 6.50 ± 0.41 1.462 1.285, 1.638 <0.001a 0.010 −0.005, 0.026 0.184b Mean ± SD (cm) Compared with preoperative Compared with postoperative 1 month Differences 95% CI P value Differences 95% CI P value Preoperative 8.08 ± 0.63 — — — — — — Postoperative1 month 6.57 ± 0.52 1.502 1.401, 1.603 <0.001a — — — Postoperative3 months 6.61 ± 0.52 1.491 1.360, 1.624 <0.001a 0.016 0.003, 0.028 0.018b Postoperative6 months 6.53 ± 0.43 1.477 1.329, 1.626 <0.001a 0.011 −0.002, 0.025 0.103b Postoperative12 months 6.50 ± 0.41 1.462 1.285, 1.638 <0.001a 0.010 −0.005, 0.026 0.184b aStatistically significant difference versus preoperative (P < 0.05, paired t test). bStatistically significant difference versus postoperative 1 month (P < 0.05, paired t test). SD, standard deviation. View Large Table 1. Forehead Length Preoperatively and Postoperatively Mean ± SD (cm) Compared with preoperative Compared with postoperative 1 month Differences 95% CI P value Differences 95% CI P value Preoperative 8.08 ± 0.63 — — — — — — Postoperative1 month 6.57 ± 0.52 1.502 1.401, 1.603 <0.001a — — — Postoperative3 months 6.61 ± 0.52 1.491 1.360, 1.624 <0.001a 0.016 0.003, 0.028 0.018b Postoperative6 months 6.53 ± 0.43 1.477 1.329, 1.626 <0.001a 0.011 −0.002, 0.025 0.103b Postoperative12 months 6.50 ± 0.41 1.462 1.285, 1.638 <0.001a 0.010 −0.005, 0.026 0.184b Mean ± SD (cm) Compared with preoperative Compared with postoperative 1 month Differences 95% CI P value Differences 95% CI P value Preoperative 8.08 ± 0.63 — — — — — — Postoperative1 month 6.57 ± 0.52 1.502 1.401, 1.603 <0.001a — — — Postoperative3 months 6.61 ± 0.52 1.491 1.360, 1.624 <0.001a 0.016 0.003, 0.028 0.018b Postoperative6 months 6.53 ± 0.43 1.477 1.329, 1.626 <0.001a 0.011 −0.002, 0.025 0.103b Postoperative12 months 6.50 ± 0.41 1.462 1.285, 1.638 <0.001a 0.010 −0.005, 0.026 0.184b aStatistically significant difference versus preoperative (P < 0.05, paired t test). bStatistically significant difference versus postoperative 1 month (P < 0.05, paired t test). SD, standard deviation. View Large Figure 4. View largeDownload slide Changes in forehead length from preoperatively to postoperatively. *Statistically significant difference vs preoperative (P < 0.05, paired t test). Preop, preoperative; postop, postoperative. Figure 4. View largeDownload slide Changes in forehead length from preoperatively to postoperatively. *Statistically significant difference vs preoperative (P < 0.05, paired t test). Preop, preoperative; postop, postoperative. Compared with the preoperative forehead length, the forehead length was significantly less after surgery at 1 month (difference, 1.502; 95% confidence interval [CI], 1.401 to 1.603; P < 0.001), 3 months (difference, 1.491; 95% CI, 1.360 to 1.624; P < 0.001), 6 months (difference, 1.477; 95% CI, 1.329 to 1.626; P < 0.001), and 12 months (difference, 1.462; 95% CI, 1.285 to 1.638; P < 0.001) (Table 1; Figure 4). The forehead length was slightly greater at 3 months postoperatively than at 1 month postoperatively (difference, 0.016; 95% CI, 0.003 to 0.028; P = 0.0178). However, the forehead lengths were not significantly different at 1 month and 6 months postoperatively (difference, 0.011; 95% CI, −0.002 to 0.025; P = 0.1032) or at 1 month and 12 months postoperatively (difference, 0.010; 95% CI, −0.005 to 0.026; P = 0.184) (Table 1), indicating that the amount of forehead length reduction was maintained during the follow-up period. Preoperative and postoperative photographs of representative patients who underwent our hairline lowering surgery technique are shown in Figure 5 and Supplemental Figure 1, and change of scar is shown in Supplemental Figure 2. Figure 5. View largeDownload slide Preoperative and postoperative photographs of this 27-year-old woman who underwent our hairline lowering procedure and received 18-mm reduction postoperatively. (A,D) Preoperatively, (B,E) 16 months postoperatively, and (C,F) 18 months postoperatively. Figure 5. View largeDownload slide Preoperative and postoperative photographs of this 27-year-old woman who underwent our hairline lowering procedure and received 18-mm reduction postoperatively. (A,D) Preoperatively, (B,E) 16 months postoperatively, and (C,F) 18 months postoperatively. Most complications were minimal (Table 2). Hypoesthesia of scalp at immediate postoperative period was observed in 91 patients (100%). Hypoesthesia of the scalp was monitored for 3 to 6 months postoperatively; it resolved in all patients. Other potential complications, such as a visible scar, segmental alopecia, and severe pain or discomfort, were not observed. Only one patient developed a complication, which was a hematoma requiring operative evacuation. The hematoma presented as swelling with fluctuation 13 days after surgery. She had previously undergone forehead augmentation using silicone implants, and during reoperation, a hematoma was observed within the capsule surrounding the implant. It is likely that blood flowing during surgery stagnated under the implant to form the hematoma. The implant was removed and the area thoroughly irrigated before closing the subcutaneous tissue and skin. Subsequent healing was uneventful. The 3 other patients with prior silicone implants experienced no complications. Table 2. Complications After Surgery Complications No. of patients (%) Wound dehiscence 0 (0) Hematoma 1 (1.1) Temporary hypoesthesia (recovered within 6 months postoperatively) 91 (100) Permanent hypoesthesia 0 (0) Visible scar 0 (0) Segmental alopecia 0 (0) Severe pain or discomfort 0 (0) Complications No. of patients (%) Wound dehiscence 0 (0) Hematoma 1 (1.1) Temporary hypoesthesia (recovered within 6 months postoperatively) 91 (100) Permanent hypoesthesia 0 (0) Visible scar 0 (0) Segmental alopecia 0 (0) Severe pain or discomfort 0 (0) View Large Table 2. Complications After Surgery Complications No. of patients (%) Wound dehiscence 0 (0) Hematoma 1 (1.1) Temporary hypoesthesia (recovered within 6 months postoperatively) 91 (100) Permanent hypoesthesia 0 (0) Visible scar 0 (0) Segmental alopecia 0 (0) Severe pain or discomfort 0 (0) Complications No. of patients (%) Wound dehiscence 0 (0) Hematoma 1 (1.1) Temporary hypoesthesia (recovered within 6 months postoperatively) 91 (100) Permanent hypoesthesia 0 (0) Visible scar 0 (0) Segmental alopecia 0 (0) Severe pain or discomfort 0 (0) View Large Patient satisfaction results are shown in Table 3. The mean satisfaction score was 4.75, and all patients who underwent this surgery were overall satisfied or very satisfied with their outcome. Table 3. Patient Satisfaction Survey No. of patients (%) 1. Very dissatisfied 0 (0) 2. Dissatisfied 0 (0) 3. Neither satisfied or dissatisfied 0 (0) 4. Satisfied 22 (24.2) 5. Very satisfied 69 (75.8)  Total 91 No. of patients (%) 1. Very dissatisfied 0 (0) 2. Dissatisfied 0 (0) 3. Neither satisfied or dissatisfied 0 (0) 4. Satisfied 22 (24.2) 5. Very satisfied 69 (75.8)  Total 91 View Large Table 3. Patient Satisfaction Survey No. of patients (%) 1. Very dissatisfied 0 (0) 2. Dissatisfied 0 (0) 3. Neither satisfied or dissatisfied 0 (0) 4. Satisfied 22 (24.2) 5. Very satisfied 69 (75.8)  Total 91 No. of patients (%) 1. Very dissatisfied 0 (0) 2. Dissatisfied 0 (0) 3. Neither satisfied or dissatisfied 0 (0) 4. Satisfied 22 (24.2) 5. Very satisfied 69 (75.8)  Total 91 View Large DISCUSSION Many previous studies regarding facial rejuvenation focused on the position of the eyebrows and wrinkles on the forehead as well as other parts of the upper one-third of the face. However, there is a growing demand for correcting high hairlines in pursuit of a smaller face. Individuals with long and wide foreheads because of a high hairline have faces with unbalanced vertical thirds, causing them to appear unbalanced, old, and more masculine. Various methods are used to address a high hairline. Nonsurgical means include make-up, tattooing, or wigs. Surgical methods involve hair transplantation and scalp advancement. Hair transplantation surgery is traditionally considered the gold standard for hairline lowering or alopecia.6,7 Hair follicles are collected and implanted one by one during this surgery, which is the most common method of improving a high hairline. However, this is labor intensive, time consuming, and costly. In addition, the results must be followed for a long period of time for potential receding of the hairline. The surgery is not satisfactory if appropriate density of hair follicles is not maintained in the long-term. As an alternative to hair transplantation, hairline lowering surgery using scalp advancement can be used to amend a high hairline. Various methods have been introduced to lower the scalp, including techniques using bone tunnels and screws. In most studies published so far, advanced scalps were fixed using Endotine, which is a bioabsorbable implant composed of a poly-glycolic acid and poly-lactic acid mixture. It consists of a 3.75-mm bone peg and 3.0- to 3.5-mm tines; the peg is inserted into bone and the advanced soft tissue is positioned on the tines.10,11 Endotine has been used in scalp advancement hairline lowering surgery because it is convenient, and the bone pegs are securely placed. However, Endotine has a few disadvantages, including palpability, early loss of traction power because of tine absorption, and tenderness near the prosthesis.10-12 In 1999, Guyuron et al reported a method for shortening a long forehead using an advancement scalp flap.3 They classified patients according to the degree of forehead wrinkles and severity of forehead elongation. For patients with mild to moderate elongation, they performed a subgaleal or subcutaneous forehead lift and a pretrichial incision, and for patients with severe elongation, they performed a subgaleal or subcutaneous forehead lift and a scalp advancement flap utilizing anchor sutures to the cranium. Their procedure achieved shortening of the forehead accompanied by brow lifting.3 Our technique, although not new, is similar to Guyuron’s method, but it has some differences and several advantages compared with this and other previous techniques. In Guyuron’s procedure, undermining is extensive posteriorly and bone tunnels are placed at multiple areas from posterior to anterior. However, the incision of our procedure limited from frontal hairline to area of temporal recession, and galeotomy was not performed. Therefore, recovery may be faster than previous procedures. Also, our procedure is a hairline lowering procedure only, although Guyuron’s procedure could be accompanied by a brow lift or forehead lift. However, when a more extensive incision would be required, this procedure can be modified and employed in conjunction with brow elevation or forehead lift. We use a bone tunneling method with anchor sutures as an alternative to Endotine. In this method, multiple V-shaped tunnels are made in the skull using a drill, threads that are fixed on the scalp pass through these tunnels, and finally, the advanced scalp is fixed at the appropriate location. This method is as effective as Endotine in advancing the scalp and is associated with minimal side effects. However, it must be performed carefully because the drill may penetrate the inner table of skull during the bone tunneling process, resulting in hemorrhage and cerebrospinal fluid leakage. We developed a special device to avoid such problems. Because the mean frontal and parietal bone thickness is 3 to 6 mm where bone tunneling occurs,13 a guard that stops the drill bit from advancing more than 5 mm prevents inner table penetration (Figure 6). The galea is sutured together slightly behind the incision line with 2-0 PDS after bone tunneling, and the thread is then pushed through the bone tunnel. The scalp flap should cover the knot so it does not irritate the incision. These procedures are helpful to maintain the reduction amount after surgery and create a good scar from enabling the tension-free sutures. Figure 6. View largeDownload slide Device and procedure used for bone tunneling. (A) Guard device used to protect the inner table of the skull. (B) Creation of bone tunnels using the guard device. Figure 6. View largeDownload slide Device and procedure used for bone tunneling. (A) Guard device used to protect the inner table of the skull. (B) Creation of bone tunnels using the guard device. Some may be concerned that bone tunneling plus PDS may not provide adequate fixation. However, the tensile strength period of PDS is prolonged, potentially exceeding the time to complete absorption of PDS (Table 3). In addition, unlike Endotine, PDS is not palpable during fixation. It is also less costly than Endotine and is thus a suitable alternative economically. Excessive wound tension, producing scar widening and tension alopecia, may occur if the amount of flap advancement surpasses scalp laxity. It is important to measure scalp laxity preoperatively to avoid this complication and ensure the use of sufficient number of fixation points. We used 4 to 6 fixation points, but additional research is required to determine the optimum number. Platelet-rich plasma was injected into the area surrounding the incision line immediately after surgery to minimize stress on the hair follicles and support wound healing.14,15 An additional 1- to 2-mm advancement can be achieved by performing galeotomy, according to previous studies.16 If the amount of reduction is insufficient because of inadequate scalp laxity, galeotomy may be conducted during the same operation. However, the incision must be extended to the temple side to create a sufficient space for the galeotomy. If galeotomy is executed too deeply, side effects such as hair loss and scarring may occur. In the current study, galeotomy was not performed at the same time to avoid these complications. Most of our patients experienced hypoesthesia on the frontal scalp after surgery. This was caused by damage to the supraorbital and supratrochlear nerves that extend from the forehead to the scalp. Maintaining the neurovascular bundle of the lateral supraorbital nerve during forehead tissue excision reduces the risk of hypoesthesia. However, leaving the soft tissue may create lateral bunching postoperatively, and total excision is required if the tissue hinders flap advancement. If full-layer excision is performed, areas of hypoesthesia may be common in the initial period after surgery. However, all patients in the current study recovered within 3 to 6 months postoperatively, and the extent of excision did not seem to have a substantial effect on the recovery rate and progress. The study has several limitations. One limitation relates to its retrospective nature and lack of patient randomization. Furthermore, the number of cases was relatively small, and the follow-up period was relatively short, which prohibited evaluation of long-term complications such as scar changes. Additionally, a validated scar evaluation tool was not used when assessing outcomes. However, we did determine the amount of forehead reduction and patient satisfaction, which are useful patient-centered outcomes. Further investigations are required to compare different methods of hairline lowering surgery for various parameters, including scar outcomes. CONCLUSIONS We accomplished hairline lowering surgery by scalp advancement using multiple bone tunnels, leading to successful changes in the ratio of the upper third of the face. The mean amount of scalp advancement was 18.37 ± 2.90 mm, which produced a statistically significant reduction in forehead length at 1, 3, 6, and 12 months after surgery compared with preoperatively. The reduced forehead length was maintained during follow-up. No severe complications occurred. Our hairline lowering method utilizing bone tunnels with anchoring sutures (and without galeotomy) thereby produces immediate and well-maintained effects and is relatively safe. It is a reasonable alternative to hairline lowering surgery using Endotine. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Acknowledgments Drs. Min and Jung are co-first authors. REFERENCES 1. Freilinger G . Proportions of the aesthetic face . Eur Surg. 1985 ; 17 : 61 . Google Scholar Crossref Search ADS 2. Marten TJ . Hairline lowering during foreheadplasty . Plast Reconstr Surg. 1999 ; 103 ( 1 ): 224 - 236 . Google Scholar Crossref Search ADS PubMed 3. Guyuron B , Behmand RA , Green R . Shortening of the long forehead . Plast Reconstr Surg. 1999 ; 103 ( 1 ): 218 - 223 . Google Scholar Crossref Search ADS PubMed 4. Connell BF , Marten TJ . The male foreheadplasty. Recognizing and treating aging in the upper face . Clin Plast Surg. 1991 ; 18 ( 4 ): 653 - 687 . Google Scholar PubMed 5. Farkas LG , Kolar JC . Anthropometrics and art in the aesthetics of women’s faces . Clin Plast Surg. 1987 ; 14 ( 4 ): 599 - 616 . Google Scholar PubMed 6. Guyuron B , Rowe DJ . How to make a long forehead more aesthetic . Aesthet Surg J. 2008 ; 28 ( 1 ): 46 - 50 . Google Scholar Crossref Search ADS PubMed 7. Klatsky SA . Forehead plasty for facial rejuvenation . Aesthet Surg J. 2000 ; 20 : 416 - 426 . 8. Kang MS , Park JW , Kang YW , Lee JS . Shortening foreheadplasty; minimization of the tension of scalp flap . Arch Aesthetic Plast Surg. 2013 ; 19 : 34 - 40 . Google Scholar Crossref Search ADS 9. Fagien S , Carruthers JD . A comprehensive review of patient-reported satisfaction with botulinum toxin type a for aesthetic procedures . Plast Reconstr Surg. 2008 ; 122 ( 6 ): 1915 - 1925 . Google Scholar Crossref Search ADS PubMed 10. Chowdhury S , Malhotra R , Smith R , Arnstein P . Patient and surgeon experience with the endotine forehead device for brow and forehead lift . Ophthalmic Plast Reconstr Surg. 2007 ; 23 ( 5 ): 358 - 362 . Google Scholar Crossref Search ADS PubMed 11. Servat JJ , Black EH . A comparison of surgical outcomes with the use of 2 different biodegradable multipoint fixation devices for endoscopic forehead elevation . Ophthalmic Plast Reconstr Surg. 2012 ; 28 ( 6 ): 401 - 404 . Google Scholar Crossref Search ADS PubMed 12. Berkowitz RL , Apfelberg DB . Preliminary evaluation of a fast-absorbing multipoint fixation device . Aesthet Surg J. 2008 ; 28 ( 5 ): 584 - 588 . Google Scholar Crossref Search ADS PubMed 13. Hwang K , Kim JH , Baik SH . The thickness of the skull in Korean adults . J Craniofac Surg. 1999 ; 10 ( 5 ): 395 - 399 . Google Scholar Crossref Search ADS PubMed 14. Lee SH , Zheng Z , Kang JS , Kim DY , Oh SH , Cho SB . Therapeutic efficacy of autologous platelet-rich plasma and polydeoxyribonucleotide on female pattern hair loss . Wound Repair Regen. 2015 ; 23 ( 1 ): 30 - 36 . Google Scholar Crossref Search ADS PubMed 15. Kang JS , Zheng Z , Choi MJ , Lee SH , Kim DY , Cho SB . The effect of CD34+ cell-containing autologous platelet-rich plasma injection on pattern hair loss: a preliminary study . J Eur Acad Dermatol Venereol. 2014 ; 28 ( 1 ): 72 - 79 . Google Scholar Crossref Search ADS PubMed 16. Seery GE . Surgical anatomy of the scalp . Dermatol Surg. 2002 ; 28 ( 7 ): 581 - 587 . Google Scholar PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Hairline Lowering Surgery With Bone Tunneling Suture Fixation: Effectiveness and Safety in 91 Patients
JF - Aesthetic Surgery Journal
DO - 10.1093/asj/sjy304
DA - 2019-04-08
UR - https://www.deepdyve.com/lp/oxford-university-press/hairline-lowering-surgery-with-bone-tunneling-suture-fixation-0qKYEHbkHA
SP - NP97
VL - 39
IS - 5
DP - DeepDyve
ER -