While a noticeably high hairline is not uncommon in those of Asian descent, it is sometimes viewed by women as a masculine trait or an indication of advancing age, can limit hair styles, and makes some women feel self-conscious. For the most part a genetic feature, a high hairline has been said to occur more frequently in the "Chinese," but this is most likely an oversimplifiation massing together all East Asians into its largest nationality.
Exactly what constitutes "too high" will vary with the size of the face and the perceived balance and harmony of the forehead with other facial features. While some experts maintain that a hairline measuring 5-6 cm above the brows is the most typical desirable female height, an equally useful metric would seem to be "you know it when you see it."
A hairline that does not start until very high up may overexpose the normal backward curve or dome of the upper forehead and give the impression that it is retruded, or too sloped. A high forehead may also shift the focus of a viewer's attention away from the subject's eyes and onto the high expanse of skin above them. In extreme cases, the scalp hair may point upward and appear to sit only on top of the head.
In cases where compensatory hairstyling yields insufficient camouflage, some women may seek cosmetic surgical hairline lowering. The most common operation offered is follicular unit hair graft transplantation applied just in front of the existing high hairline. While effective, the operation often needs to be repeated several times to achieve optimum hair density. Growth from graft to full normal hair length may take a very long time. Expenses can be high.
Alternatively, a less expensive, one-stage operation known as forehead reduction can lower the hairline 2-3 cm or more. It has been called a "reverse upper facelift," at least for the hair.
Described simply, a wide full-thickness strip of forehead skin beginning at the fine hairs of the anterior hairline is excised after nearly the entire scalp has been mobilized and advanced forward. The wound is sutured in several layers to reduce skin tension.
If the forehead is not flexible enough to allow for adequate tissue removal or needs extensive lowering, a balloon-like tissue expander may be implanted two months before the operation to stretch out the overlying skin, thus allowing large amounts (up to 10 cm) to be excised.
Normal forehead reduction does not by itself lift the brows. Especially in older patients with drooping brows, hairline lowering surgery may be combined with brow lift through the same incision to further shorten the height of the forehead.
Recovery to a cosmetically acceptable appearance is rapid, especially in those with lighter skin tones. Numbness in the front part of the scalp is expected. Normal activity may be resumed in a week or so, although swelling and bruising may last for several weeks. Once healed, the new hairline appears acceptably natural, sensation usually returns over several months, and the incision becomes harder to see.
At times, forehead reduction surgery may be combined with limited hair transplantation to better soften the final scar or in the region of the temples, where reduction surgery offers less help.
Optimal outcomes with forehead reduction flap surgery are generally achieved in patients with dense hair and an inherited high forehead. In those with smaller or localized patches of thinning associated with aging, hair transplantation is usually adequate.
Patients with darker Asian skin pigmentation may take longer for scarring to become inconspicuous. Some may benefit from micropigmentation of the scar (permanent makeup) that not uncommonly ends up lighter than the surrounding skin.
Not all cosmetic surgeons favor forehead reduction and note that a lowered hairline may look more natural after hair transplantation since the the normal sweep of the female hairline involves cowlicks, mounds, and other irregular features that are very hard to mimic with forehead reduction surgery. Plus, scarring after hair transplantation is essentially nil while with reduction surgery is sometimes noticeable in color or thickness, especially when the hair is pulled back.
Hairline lowering procedures may offer superior results in some patients in whom forehead implant surgery has been recommended for excessive sloping.
While placement of implants can increase forward projection of the mid and upper forehead, they do nothing to lower an overly high hairline, which may be the very problem most responsible for a patient's cosmetic concerns.