CosmeticSurgery.com Staff Report
Medically reviewed by: Arian Mowlavi, M.D.

Many women find their hairlines receding, leaving them with what appears to be an oversized forehead that hints at thinning hair. But plastic and cosmetic surgeons are using surgical scalp transfer and hair transplantation to put hairlines lower. Those procedures allow a woman's face to have the classic proportions of beauty.

When C.B., now 34, of Boise, Idaho, sat down before her dressing table mirror a couple of years ago, she studied her face - yet again. She had never been quite satisfied with her appearance although people often remarked her dark Gallic features made one very attractive woman. Close friends usually added it was ridiculous for her to even consider cosmetic surgery.

"But I always felt naked if my hair blew back and people saw my large forehead," C.B. told CosmeticSurgery.com. "I've always studied faces and admire balance and symmetry but knew mine was somehow unbalanced."

So she picked up an eyebrow pencil, drew a line several inches above her eyebrows and studied it for a moment. C.B. then filled in the area between her hair and the line with the pencil. "That's the solution!" she shouted. "I never knew that was what was wrong with my face!"

C.B., who then lived in Florida, started looking for a hair restoration surgeon by asking friends for referrals and searching online physician listings. Finally, she chose Jeffrey S. Epstein, M.D., a plastic surgeon with offices in Miami and New York City. She liked the information on his website and, later, chose him because he listened carefully during the initial consultation.

"I even pulled the pen out of his hand - without him objecting -- and drew my own surgical markings across my forehead to show where and how I wanted my hairline," C.B. says. "I've always admired Jennifer Lopez and wanted her oval hairline. And, I was so tired of hiding my forehead under long bangs."

C.B. then had five hours of hair transplants at Dr. Epstein's office.

According to the Beverly Hills Institute of Aesthetic & Reconstructive Surgery, many more women are reporting to hair restoration surgeons with complaints of a hairline that is just too high. They dislike the condition because it often hints at balding and the overall thinning of a woman's crowning glory.

Moreover, experts say the traditional standard of beauty and facial harmony require a face that is divided into equal thirds; when the face shows a forehead that is too broad, the accepted symmetry is thrown out of whack. Consequently, many women like C.B. spend considerable time camouflaging that unwanted feature.

The first approach is usually getting more hair to grow by slathering a drug, Minoxidil, the only scientifically proven topical (applied to the skin) therapy to stimulate hair growth.

Yet another patient, a 43-year-old Chicago native (who requested anonymity) said she suffered in silence for years with a high hairline. And then, eight years ago, she found -- by searching online listings -- and used a surgeon in the Golden State (California) who offered hairline advancement. Years later, on a return visit to the same physician, she applied for an opening at the surgeon's office, was hired, moved to West Hollywood with her lawyer husband and now counsels other women interested in covering a bulbous forehead.

"While I hear from women all over the world about hair loss problems, 30 percent of my emails are from women wanting high hairlines surgically lowered," she says. "They are surprised to learn a treatment is available."

Actually, female hair loss in general is a surprisingly common complaint. According to the American Academy of Dermatology, about 30 million U.S. women are affected by some form of hair loss.

"I usually do several hairline advancement procedures monthly on women," says Jeffrey Epstein, M.D., the plastic surgeon who allowed the irrepressible C.B. to draw her own presurgical markings. "Because so many of my patients are women, I founded the Women's Center for Hair Loss."

Adds James Harris, M.D., a Denver plastic surgeon and co-author of "The Hair Replacement Revolution," a 2003 tome about all types of male and female hair replacement: "Hair loss in women can be genetic but is often caused by underlying medical conditions like anemia, thyroid disease, connective tissue disease, gynecological conditions and emotional stress."

However, there's an unsuspected culprit at work, causing some high hairlines.

"It often comes as a surprise to patients that a risk of some facial plastic surgery is a high hairline," says Alan Bauman, M.D., a Boca Raton, Florida, hair restoration physician who says 40 percent of his patients are women with hair woes. "One of the usual, expected risks to a face or brow lift is causing the hairline to recede an inch or more," Dr. Bauman says. "The loss is caused when a long incision for a facial procedure is hidden within the hairline. Moreover, some skin - along with its hair -- is often excised from a woman's sideburn area during facial plastic surgery."

Plastic surgeon Sheldon S. Kabaker, M.D. in Oakland, California says he gets the best and most attractive results by surgically advancing a woman's hairline to the point on her forehead where the skull starts to slope downward. "On the average women, that's about an inch above the eyebrows," Dr. Kabaker says.

Surgeons have two basic ways of moving a lofty hairline closer to a patient's eyebrows: they can transplant hair into the bare sections or they can excise about an inch of skin and pull the hairline down.

"Both have advantages and disadvantages," says Dr. Kabaker. "Hair transplantation can require two or three, day-long procedures six months apart and may take two to four years for the full growth to become visible. Hair advancement by surgery, however, shows immediate results but dealing with the scar can be tricky."

Says Toby Mayer, M.D., a Beverly Hills plastic surgeon who specializes in hair replacements: "Transplanted hair usually grows in kinky and wiry, like the fibers in a Brillo Pad. The hair is rarely ever the same texture again. Plus, because hair transplantation is so labor intensive, it costs four times as much as removing a small strip of skin at the hairline."

If patient and doctor opt for hair transplantation, the surgeon first takes a close look at the patient's donor areas -- usually the scalp just above the nape of the neck and just over the ears -- to make sure enough healthy hair is available. Then, the surgeon, along with up to three assistants, will slowly, carefully take hair from the donor sites and later separate it all into tiny grafts, or "hair seeds." Those seeds are then painstakingly inserted into holes about the size of a needle puncture in the balding area. After that, Mother Nature takes over; the transplanted hair falls out but is replaced by new hair growth. After about six months, the surgeon evaluates it all and perhaps orders another session -- which requires yet another transplant session followed by a six-month growing period. Dr. Epstein says he asks his hair transplantation patients to use Minoxidil once daily for the first three months following the procedure, to stimulate the regrowth of transplanted hairs.

"Minoxidil seems to reduce the interval between the procedure and when the hair starts to grow from four to about two and a half months, "says Dr. Epstein.

Some surgeons prefer to advance a patient's hairline by surgically removing a narrow strip of hairless skin right where the hairline and forehead meet. Using that procedure, and with the patient under general anesthesia, the surgeon makes a zigzag incision across the forehead, just a couple of hairs into the fine hair of the hairline. The surgeon then buries the hair edge when he sutures the two edges together so that hair grows in -- and just in front of -- the scar. When the incision is sewn together, the scar is well hidden and fades over three to six months. Just days after the operation, the patient can flop her hair over the fresh scar and return to her normal activities. Stitches are usually removed in seven to ten days. In a second variation, the surgeon combines hair advancement with a brow lift.

"If I perform a surgical hairline advancement on a woman's forehead on a Thursday, she can usually go back to work on Monday," says Dr. Mayer. "The hairline is immediately lowered and there is no change in the texture of the hair. Plus, it costs four times less." Adds Dr. Kabaker: "Surgical hair advancement requires the utmost in care, though, because the surgeon works close to critical blood vessels and nerves in the forehead, brow and scalp."

If a patient has a tight scalp, or if the hairline needs to be advanced more than an inch, the surgeon can create another inch or so of skin by installing a device known as a tissue expander under the skin. That is basically a balloon that is inflated over a six-week period to stretch the scalp. Most surgeons let their patients know well before the procedure that there will be an initial period of disfigurement. That distresses some patients who expect an immediate improvement in appearance just after the operation. But consider what C.B. reported just after her hairline advancement:

"I felt gorgeous the week after the procedure and heard comments from people like: 'You just look better and better every time I see you!' And, 'Are you Italian?' and 'You are the most beautiful girl I've ever seen!' "Well, O.K., that last guy was in a bar had been drinking but I still took the compliment to heart and have never felt as pretty. The operation has really changed my life," she says.

And why not? In the immortal words of church reformer Martin Luther, hair is the richest ornament of a woman.