Feminine Hairline: Coronal Approach or Scalp Advancement?
This informative article responds to some of the questions that often arise related to a surgical lowering through the hairline, the coronal approach and how to redefine the format for a more feminine hairline.
First, we should analyze the general characteristics of the hairline, both male and female:
The first two or three lines of hair that comprise the hairline are made up of follicular units with only one hair, followed by follicular units with 2 hairs (Fig. 1 and Fig. 2). This makes the hairline unique with respect to the rest of the hair.
Keep in mind, the hairline itself is naturally irregular, with hairs distributed randomly (Fig. 3).
Secondly, we should define a set of basic concepts before getting into the subject matter:
To reach the forehead and do the bone recontouring, it is necessary to enter through the scalp and detach it from the bone.
There are two main ways to reach the forehead bone (frontal bone): an approach through the hairline (direct incision over the hairline) or a coronal approach (incision located in the top of the head, hidden within the hair).
Both approaches (hairline and coronal), not only serve as an access point to the forehead, but also can redefine the format and/or increase the hair density on the hairline. With the hairline approach, or surgical lowering, the hairline is physically pulled down. On the other hand, the coronal approach, takes advantage of the follicular units obtained from the scalp for an immediate hair transplant in the alopecic areas, such as where the hair is receding at the temples and/or the central hairline.
10 points to consider for a more feminine hairline
Having defined these general concepts, we identify and analyze the advantages and disadvantages associated with surgically lowering the hairline in comparison to redesign of the hairline through hair transplants. To that end, we have created a 10-point guide to explain all the particular factors related to these hairline feminizing procedures:
There is a significant difference between the male and female hairline formats. Very generically speaking, the feminine hairline has a more rounded format, while the male hairline is M-shaped due to the presence of receding hairlines at the temples (Fig. 4).
In our 2017 publication (Capitán et al. Facial Feminization Surgery: Simultaneous Hair Transplant during Forehead Reconstruction. Plast Reconstr Surg 2017;139(3):573-584), we used a study of 492 patients to describe the hairline types found in transgender patients, distinguishing 5 types (Fig. 5).
Many patients argue that surgical hairline lowering can, in some way, modify the format, when what this technique really does is simply lower the hairline, but maintaining the same format to a large extent all the while. In other words, if we lower an M-shaped hairline, in the end we just get an M-shaped hairline that is further down (Fig. 6).
Receding hairline and temples
Despite the widespread belief that scalp advancement surgery can be used to correct or decrease receding hairlines at the temples, this is actually not completely accurate. In fact, it is difficult to find results either online or in the scientific literature that show cases where the temples have been satisfactorily corrected by surgery. Using different techniques, surgery can try to eliminate alopecic areas at the temples, but the common consequence is the presence of visible scar tissue and the complete loss of a natural hairline (Fig. 7).
When a hairline is surgically lowered, the sector where the lowering is most obvious is usually the middle, since the side areas generally have some recession and do not lower to the same level. For this reason, there is some risk that after surgical lowering, the height of the forehead at the central area will be too short, not congruent with a feminine hairline.
Modifying the hairline height after a coronal approach
A common cause of concern for some patients is the possibility that the hairline will recede after an anterior or posterior coronal approach (Fig. 8).
After an anterior coronal approach, the hairline recedes some 2-3 mm. After a posterior coronal approach, the recession is less than 1 mm. In addition to being an insignificant distance, the overall result is scarcely affected. Since the eyebrow positions, which are higher after surgery, can be modified simultaneously, the distance between the eyebrows and hairline remains the same (Fig. 9).
At this time, we are finishing a study to be published where we measure the height of the hairline before and after surgery in patients with a coronal approach. We intend to show that the impact on the hairline is insignificant and justify its use (Fig. 10).
Loss of density and naturalness
When a surgical hairline lowering is done, the incision is usually hidden 1 or 2 millimeters behind the hairline, which can affect hair density in this area and also permanently eliminate the natural irregularity of the hairline shape, as not even the best surgical scar design can reproduce the random distribution of the hairs in the first hairline rows.
This is possibly the main risk and without a doubt the biggest complication associated with surgical hairline lowering. This scar is in a highly exposed location with an occasional tendency to be considerably wide if the surgical closure was done with tension. In recent years, we’ve received a large number of patients with highly visible scars due to a hairline lowering surgery and we can affirm that this is a very difficult complication to resolve (Fig. 11).
After poor scarring, recovering healthy and normal tissue is quite difficult. On the contrary, a coronal approach incision is hidden in the scalp (Fig. 12).
Hair transplant after surgical hairline lowering
One common question that some patients have is about the possibility of doing a hairline lowering and then complementing it with a hair transplant. The main problem associated with this option is that a transplant on previously operated and scarred tissue has a lower success rate and, as such, runs the risk of a final low density, in addition to a possible visible scar and almost certain loss of the naturalness of the hairline.
Based on our experience, eyebrow repositioning is more predictable and offers better control of the symmetry when a coronal approach is used, since it allows for precise and simultaneous control in the placement of both eyebrows and respects their natural arch. Controlling the eyebrows through a hairline approach is potentially less predictable and more subject to possible asymmetries, since the positioning is done on an individual basis. Moreover, since HLS uses sutures, the result may be some alteration of the eyebrow arch with unnatural and/or unharmonious formats. Our system to fix and reposition the eyebrows using resorbable multipoint anchoring devices (Endotine), gives us precise control and significantly decreases the possibility of asymmetrical results (Fig. 13).
Despite popular opinion favoring hairline lowering approaches, there is actually almost no scientific evidence to support this procedure, since a very small number of papers have been published to explain the technique in detail, analyzing its advantages and showing short-, medium- and long-term results in a large population. Moreover, no publication has substantiated the use of a hair transplant after a surgical hairline lowering. This lack of scientific evidence calls the technique into question and makes it difficult to respond to the many concerns related to it.
We have occasionally explained that the last few years have given us the chance to consolidate a specific surgical technique: forehead reconstruction via coronal approach, which has shown itself to be reliable and reproducible and has also produced satisfactory results (Capitán et al. Facial feminization surgery: the forehead. Surgical techniques and analysis of results. Plast Reconstr Surg 2014;134(4):609-19). Implicit in this technique, is the obtention of a cutaneous fragment of the scalp (Fig. 14).
This creates an unique opportunity to take advantage of the follicles present in this fragment, particularly when the patient is a candidate for hairline feminising. The simultaneous hair transplant (SHT) involves significant cost for the patient and increases the overall price of surgery. The increased cost is due to the fact that the technique requires a highly specialized hairline* transplant team made up of two specialist surgeons and an average of six hair microscope technicians (Fig. 15).
If for some reason the patient opts out of a simultaneous transplant, but believes that they may want to feminise their hairline in the future (due to low density, visible receding areas, etc.), they can always have a deferred hair transplant later.
*The simultaneous hairline transplant technique varies substantially from standard hair grafting techniques.
Final note on SHT: a feminine hairline and forehead, simultaneously
Finally, we’d like to stress the viability of a hair transplant simultaneous to forehead recontouring. Many professionals argue that the quality of the hair obtained from the coronal area (anterior approach) is not adequate for a hair transplant. First, it is important to remember that the alopecia in patients who undergo facial gender confirmation surgery has stabilized as a result of hormone and/or specific treatments. Oral treatment with Finasteride and other anti-androgens has demonstrated its effectiveness in the treatment of androgenetic alopecia in both men and women, decreasing the progression of the phenomenon and inducing moderate new hair growth. Second, the decision about the donor area of the coronal approach (anterior or posterior) is determined in advance by an exhaustive study that includes different clinical parameters like alopecic area format, hair density, and the phenomena of miniaturization. If the density is not sufficient or the hair quality is less than ideal in the anterior coronal approach, the scalp incision is simply made in a more posterior part of the head where optimal follicles may be harvested.
Thank you for fully reading the explanations behind surgically obtaining a feminine hairline. We hope this description of the advantages and disadvantages have been clarified for a better understanding of the procedures.