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1. Cost.
Over the years, I have received many e-mails from people seeking further information about the hairline lowering procedure that is described on our site. The most frequently asked question is the cost. At present, the cost which includes surgeon’s fees, anesthesia, operating room costs, equipment and supplies and medications is approximately $7,200 for a one-stage procedure and about double that price for the two-stage procedure which includes the cost of a tissue expander. A browlift can be done at the same sitting for a very modest addtional charge.
2. The next most frequently asked question is whether I know of a surgeon in another part of the world who does this procedure.
I have spent many years performing this procedure and refining the technique. I have lectured to colleagues on this operation and have published scientific articles and texbook chapters about my experiences. Other surgeons should be privvy to this information but I cannot vouch for their actual hands on training and experience. And although the concept is straightforward, there are many fine details such as the angles of the incisions, the differences in the direction of hair growth in hairlines, the flexibility of the scalp, preservation of certain arterial supply, and other judgment factors that make it hard for me in good faith to recommend others who have any significant experience with my present technique. The basic concept should be familiar to most cosmetic plastic surgeons that do open (pretrichial or trichophytic) forehead lifts, but the subtleties of the hairline lowering are known and experienced by few. From what I see on the Internet and the questions I get in calls from other surgeons, I feel that no one will do the procedure as I do it.
I know many hair transplant surgeons who could do a good job using follicular unit grafts. If you do find someone in your area that does the hairline lowering procedure, it would be wise to ask to see before and after pictures of prior results. Also, let me know who they are for future reference.
FOR OUT OF AREA PATIENTS
I will ask for a detailed description of your condition, photos and videos and other details by e-mail interaction and eventually have a telephone consultation.
If we can determine that you are a good candidate for this procedure, we can schedule surgery on a day after a scheduled consultation. If the consultation is satisfactory for all, we can go ahead with the surgery. Patients can leave for home as early as the day after surgery. I usually can find a local colleague to perform suture removal.Therefore, one would need to stay only a minimum of two nights in the area.
For those coming from another country, I often suggest planning a vacation in the San Francisco, California area as most patients are very comfortable and presentable in a few days after surgery.
3. Another question I get frequently is, “Can I see more pictures of results on the Internet?”
If you are interested in seeing more of these cases, I suggest you come to my office for an in person consultation and I can show you early and late results of patients without having to have the possibility of them being seen and identified throughout the world. To really appreciate what the operation does, it would be best to see the whole face rather than a view from the forehead up or a patient with his/her eyes blanked out. I feel it is very important to protect patient confidentiality. Few people would want to have their identifiable features be shown indiscriminately on the Internet, and I greatly respect that. I am always grateful to those patients who give me consent to use their images. I haveover 120 hairline lowering cases in a PowerPoint presentation on my office computer of persons whom I have operated on and who have given me consent to show their pictures to prospective patients within the privacy and confidential setting of my office.
4. Another question or series of questions I would like to answer would be related to alternative methods of achieving the results, scars and individual goals.
The best alternative method is hair grafting utilizing large numbers of follicular unit grafts. This is a technique that I do routinely on men with male-pattern baldness and occasionally on females who want the alternative operation. I see a great economic and time advantage to the hairline lowering procedure with the only drawback I have found to be related to a temporary numbness of the front part of the hair-bearing scalp. As far as scars go, if one were to harvest a strip of donor material for follicular unit grafting, one would have a scar hidden within the hair which should be no more of a problem than the scar at the hairline with hair growing through it. If we did have an unfavorable scar: 1) I would not charge to revise it; 2) I could do follicular unit grafts. Sometimes we do plan on doing grafts if the hair at the temples (the acutely downward directed growing hairs) need to be brought forward. If so , customary fees for follicular unit grafts would apply.
5. Do I do this procedure on men?
I do this operation on highly selected men without male pattern baldness or who have had reconstructed hairlines. Men having this operation have to understand the progressive nature of hair loss in males and that further procedures may be required to maintain a result.
6.I am often asked with this operation and other operations about comparison cost factors.
If one were to lower the hairline, our usual 2.0 cm to 2.5 cm, we would move approximately 4000 to 6000 hairs or 2000 to 3000 follicular units. Based upon that movement, the cost is about one dollar a hair compared to grafting which in our practice would be more than twice that cost done over two or three sessions. Also, as I mentioned, with the time factor involved, the result is apparent and disguisable and cosmetically effective within two to seven days, even with sutures in place.
7. What are the side effects and potential complications of this operation?
First of all, all patients experience numbness of the front of the scalp. The sensation almost always returns in a 3-12 month period. Sometimes there is an itching sensation during the recovery period. These set of symptoms can occur after dense graft packing or any incision made in the scalp such as in facelifts and forehead /brow lifts . Second, there can be some shedding of the fine hairs in the front of the scalp within 2-4 weeks after surgery. This is called an “effluveum” and has occurred in about 2% of my surgeries. The hair has always come back after 3 months, in my experience. I sometimes suggest the use of 5% Minoxidil to the front of the hair bearing scalp after surgery. This can lessen the possible fallout and promote a more rapid growth of hairs that might have been shed and those that will be growing through the incision. Similarly, with routine hair transplants, the grafted hairs almost always fall out and goes through a three month “resting phase” before appearing again.
We do this opertion under intravenous sedation so there is no recollection of any pain. Post operatively, most patients are amazed on how comfortable the whole process was compared to any prior operations. This operation could readily be performed under local anesthesia alone, similar to a hair transplant, but I prefer my patients be totally comfortable.
As with any surgery there can be unfavorable reactions to local anesthetics, sedatives or pain medicine. The possibility of infection (I have had none so far with this procedure.) has to be stated. When expansion is involved we have to consider the possibilities of expander failure or displacement requiring removal and replacement.
8. When can I appear in public after this operation?
Most of my patients who are having the hairline lowering without a brow lift (the majority) can appear presentable within two days after the surgery. Stitches are in place along the hairline so it has to be covered by hairstyling or some apparel. Most patients are used to wearing bangs which they can again comb over the front hairline. A rare patient has bruising of the forehead and eye areas which usually can be covered by makeup early.
9. When can I wear my hair combed back and not attract attention?
Usually within three to six months, hair grows through and in front of the scar creating a natural looking result.
10. When can I travel?
Most of my patients are from out of town and often from out of the country. They can travel home the afternoon of the day after their surgery. We usually operate on Monday and Wednesdays. I prefer to see my out of area patients on Tuesdays before a reserved surgery time on Wednesday, the next day. We can have an in depth consultation to supplement any verify prior online exchange. If all is in order, we do the procedure the next day, Wednesday. Only once in did we not proceed with surgery. I see the patient the next day, (Thursday morning) and they can travel as soon as that afternoon. I recommend they consider staying another day, but most elect to travel the day after surgery. We can usually arrange for a local colleague to remove sutures 5-8 days after the operation.
11. Will I need hair transplants (follicular unit grafts) in addition to the hairline lowering?
This all depends on your situation. The hairline lowering does not work well to advance the acutely downward growing hair in the temples. For those patients who want or need these areas augmented, we can do a session of hair transplants at the same sitting as the hairline lowering. We take the donor hair for follicular unit grafts adjacent to the hairline lowering incision that extends into the posterior temple hair. Therefore, we create no additional scars. We have done up to 600 grafts with a hairline lowering procedure. I do not advocate placing grafts at, in, or in front of the hairline suture line at the time of the hairline lowering operation.
On those rare cases where a scar is unfavorable or where a strong cowlick exists, I will tell the patients that future grafts might be needed to totally disguise a scar. This arises in about 10% of cases with less than 2% having grafts.
12. I have a high hairline and it seems I am losing hair in the front. Will this operation work for me?
I might recommend having hair transplants (grafts) first or instead of the hairline lowering. Or,if a hairline lowering is done, there should be a commitment to having grafts later. The decision depends a lot on the physical findings and expectations of the patient.
13. I would like to see more pictures of your most recent work
This is similar to question 3.
It should be of interest that the last consecutive 14 cases of hairline lowering/forehead reduction (as of 8/5/2011) would not give consent for their pictures to be posted on this website. Most, however, have given me permission to show photos in the privacy of my consultation room. I have over 120 recent cases in a Powerpoint presentation that I can show during my in person consultations. I am sorry that we cannot put many of these cases on the website as they are most helpful in helping someone make a decision about correcting a problem that affects them greatly. However, I too, might feel uncomfortable that my very private appearance changes might be available for anyone in the world to see.
Sheldon S. Kabaker, M.D.