Forehead ReductionRather than how much to lower,
what to preserve together.

There is a more suitable method.

You do not need to give up either forehead reduction or hair transplantation. There is a more suitable method depending on the height and width of the forehead. It can be compared to glue and tape. The action of attaching is the same, but sometimes glue is better, and sometimes only tape can stick. The required method differs according to the situation.

If height is the main concern, consider forehead reduction first.

For women, the parting line is located in a place that is conspicuous when viewed from the front. At the parting, hairs split and do not overlap, so even with the same hair density the scalp tends to show through. If you lower the hairline a lot with hair transplantation, the density at the parting area can appear reduced and the scalp may be visible. Even with several touch-ups, it can still appear sparse.

In such cases, it is better to reduce the height first with forehead reduction.

There are many cases where we do not recommend forehead reduction.

If the concern is not the forehead height but a deep M-shape or wide lateral sides, hair transplantation is preferable. We do not recommend forehead reduction if the scalp has insufficient elasticity, the scalp is too thin, or the density at the parting area is low.

To reduce scars you must reduce tension.

The main reason the scar line widens after forehead reduction is high tension on the incision site. In other words, the greater the force pulling the scalp back, the higher the likelihood the scar will widen. There are many things to pay attention to 'from diagnosis to suturing' to reduce tension.

Diagnosis

You must accurately assess the characteristics of the scalp. If you fail to properly evaluate scalp elasticity, the result may differ from expectations. You may not be able to reduce the forehead as much as anticipated, and if you pull too aggressively the scar can widen or concomitant frontal hair loss can occur. Experience that allows accurate assessment of scalp characteristics is the first step toward a successful forehead reduction.

Design

You must design with the final hairline in mind. Consider whether hair transplantation will be needed after forehead reduction, how much of the baby hairs to preserve, how to hide scars among existing hairs, and the hair direction and thickness when designing the incision line.

Incision

Scars remain. What matters is how well they are concealed. With proper surgery, the scar remains as a thin line and is not highly noticeable, but using existing hair and baby hairs can conceal it even better. Selecting the incision location that considers existing hair and baby hairs is important.

Galea incision

Galea incision is the core of forehead reduction. It involves making incisions at regular intervals in the firm galea to allow the scalp to stretch sufficiently. Compared to simple forehead reduction without galea incision, this allows a much greater lowering of forehead height. However, galea incision is difficult to perform properly because there are many hair follicles and blood vessels just above the galea.

You must be able to perform galea incision to sufficient depth to achieve the desired amount of forehead reduction.

Fixation

There are reasons and limits to choosing fixation devices. The pulled scalp must be firmly fixed to the bone so it does not return. Devices called Endotain can be used, or fixation can be done with sutures. I prefer the Endotain method because it can suspend the scalp with maximal pull and I think its fixation strength is superior.

Using a mini Endotain usually prevents palpability from the outside.

Suturing

Skin suturing is merely supportive; it connects all the layers of the incised scalp. After subcutaneous suturing is finished, the skin surfaces of the incision often adhere before skin suturing is even done. The goal is to reduce the tension on the skin. Now we simply smooth and align the skin edges.

Both superficial and deep scars must be minimized.

If you eliminate the tension on the skin, most scars remain as a thin linear mark. While the visible scar is important, the scar beneath the skin must also be minimized. That makes subsequent hair transplantation easier. The size and amount of scar tissue affect hair transplant graft survival rates.

It should have been finished in one operation.

During revision consultations, we often see patients who had forehead reduction but did not achieve as much reduction as expected, or whose hairline that had initially lowered has risen again. When we inspect the previous surgical site during revision, sometimes the reason becomes apparent.

Reasons for insufficient lowering: galea incision

To lower the hairline significantly in forehead reduction, simply pulling the skin and scalp has limits. The process of appropriately incising and relaxing the galea so the scalp can move forward sufficiently is important. During revision surgery we sometimes find that this process was not performed adequately. Even though there was room to move the scalp further, it was closed without sufficient advancement.

The patient has gone through the burden of surgery once, yet did not fully receive the expected result.

Reasons for re-elevation: fixation

Fixation that keeps the lowered scalp in place is as important as adequately lowering it. Some patients report that the hairline was clearly lowered immediately after surgery but rose again over time. In some cases the line rose because the scar widened. When we inspect during revision, we sometimes find inadequate fixation, and occasionally we cannot find traces that fixation was performed in the previous surgery.

Lowering the hairline to the desired position is not the entire operation. Lowering it and keeping it there—both are important in forehead reduction. We consider both to be essential.

I don't want forehead reduction again.

Some patients develop distrust of forehead reduction from one experience, and even when their facial proportions or current condition suggest forehead reduction would be appropriate, they refuse further surgery and request hair transplantation only. We fully understand that sentiment. Therefore, we do not view revision surgery as simply lowering the forehead a few more centimeters.

This time the same problem should not recur. We check the remaining scalp laxity, dissect and relax the galea sufficiently as needed, and fix the lowered scalp securely so it does not re-elevate. Because we are operating on tissue that has already been operated on, revision can be more challenging than the first surgery. Nevertheless, forehead reduction revision is one of the procedures we are confident performing.

Lower it enough, maintain that position well, and consider the remaining scar when re-operating. If you were disappointed with your first forehead reduction, I hope the second surgery makes you feel, 'So this is what forehead reduction was supposed to be.'

The day we reduce the forehead, we address the profile too

When consulting about forehead reduction, some patients worry about their profile as much as forehead height. Even if the forehead has been lowered enough, hollow temples can still make the face look wide, and short sideburns can leave a strangely empty appearance when the hair is tied back. If conditions permit, lateral hair transplantation can be performed simultaneously with forehead reduction.

Wait a bit for the M-shaped areas

That does not mean we do everything at once. The M-shaped hairline often overlaps with the forehead reduction incision line and the areas that would need grafting. I think it’s important to separate what’s better to do now from what’s better to do later, rather than doing every possible procedure at once. Therefore, if grafting is needed for the M-shaped areas, I recommend waiting until the forehead reduction has settled well before performing the transplant.

Conversely, if you do not need a separate transplant for the M-shaped areas, we can transplant to the temples and sideburns at the same time.

The forehead isn't only what faces forward

When we look in the mirror we do not only see the frontal forehead. We sometimes tie our hair back, turn our head to view our profile, or examine our face in photographs. So I do not think forehead reduction is simply a matter of moving the hairline downward. The frontal forehead is addressed with forehead reduction, while the M-shaped hairline, lateral areas, temples, and sideburns are treated with hair transplantation.

If doing both at once is better, we do them simultaneously; if it’s better to wait for some areas, we wait.

Sensation becomes dulled

When touching the incision area or the scalp behind it, the skin may feel unfamiliar even though it is your own. Washing your hair can feel strange, and you may experience itching or tingling. These sensations often improve over time, but they can be bothersome during recovery.

Scars do remain

Forehead reduction involves an incision along the hairline, so it is not a surgery that leaves no scar. Initially the scar can be red and noticeable. Over time it fades and is hidden by hair, but you must wait for that to happen. In most cases it is not visible at conversational distance, and if the scar continues to bother you after time has passed, it can be covered with hair transplantation.

Endotain may be palpable

Endotain is an absorbable material that gradually disappears over time, but until then it may be felt or it may seem like the endotain is moving, which can feel unfamiliar. Using a mini endotain can reduce that sensation considerably.

Accompanying loss of nearby hair can occur

During surgery, surrounding hair can experience temporary shock, causing existing, non-operated hair to fall out. There is a period when the forehead is reduced yet the hairline looks sparse, which is when patients are most worried. Most of the hair regrows, but knowing and waiting for that fact is quite different from experiencing it without knowing. I don't want to describe this as merely a surgery that reduces the forehead by a few centimeters.

I think it's important to decide with an understanding of what time and process are required. Start by knowing not only how things might improve but also the process to get there. You should feel reassured during the process as well as with the result.