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Wednesday, January 11, 2006

The receding hairline caused by a coronal or endoscopic browlift might not be so obvious after a primary facelift, but the inching up of the hairline after subsequent touch-ups can result in a significant deformity.

A surgically elevated hair line is a tell-tale sign of cosmetic surgery. For the individual attempting not to broadcast the fact that surgery is partly responsible for his or her good looks, this can be a problem.

The open pre-hairline approach is one solution that helps surgeons avoid significant hairline changes.

E. Gaylon McCollough, M.D., a facial plastic surgeon in Gulf Shores, Ala., has used all the available techniques for lifting the drooping tissues of the forehead and eyebrows.

The founder of the McCollough Plastic Surgery Clinic and the McCollough Institute for Appearance and Health, says cosmetic surgeons tended to go the traditional route with the coronal forehead lift until about 12 to 15 years ago. "Then, the endoscope came along," he tells Cosmetic Surgery Times. "We were all enamored by it and many of us performed the endoscopic forehead lift. What became obvious was that with both the coronal and endoscopic forehead lifts, the hairline was severely elevated. So, I began looking at the alternatives."

While the direct browlift, during which surgeons make the incision just above the brow hairs, and the mid-forehead lift, where surgeons make an incision in the horizontal wrinkle line, are good operations in the right patient, and do not raise the hairline, both result in scars on the exposed forehead. In a small percentage of cases the scars are visible on close observation.

Best of all worlds

For nearly three decades in practice, Dr. McCollough has refined his approach by assessing the pros and cons of the many different options for surgical browlifting. He determined that one way to avoid raising the hairline and visible scarring is to make an incision at the hairline.

"In many of these cases, using this approach, you can actually lower the hairline if the patient already has one that is elevated," he explains. "You get closer to the eyebrow, so you can get a better browlift."

He made note when hair transplant surgeons began to advocate the trichophytic incision with scalp flap techniques, meaning the incision is made at the hairline and is cut across the hair follicles, rather than parallel to the follicles as recommended when the incision is made within the hairline.

"You undercut the flap edges and lay the skin over the beveled cut on the scalp incision edges, and the hair grows right through the scar," Dr. McCollough says. "What happens is that you get the best of all worlds--you do not raise the hairline (you might lower it) and providing you close the incision under magnification, you get a very acceptable scar, which is camouflaged by the hair growth."

The technique

The incision for the forehead portion of the facelift follows the patient's natural hairline.

"If the hairline is irregular, the incision is irregular," Dr. McCollough says. "And it is made in the manner so that one cuts tangentially across the hair follicles. As one gets to the lateral aspect of the forehead hairline, the incision then trails behind the temple tuft of hair and extends straight down inferiorly, stopping about 3 cm above the ear.

Once Dr. McCollough has made the incision, he retracts the flap and dissects down to the supraorbital rim. He frees the tissues from the supraorbital rim laterally and in the midline and flees the tissues into the glabella. He preserves the supraorbital and supratrochlear vessels and nerves. In many cases, he excises the corrugator muscles.

Dr. McCollough lifts the forehead skin superiorly and depresses the scalp inferiorly until the two overlap. He then removes the overlapping tissues.

"The key to getting the best scar is: on the flap side of the forehead skin the incision is beveled in exactly the same plane on the forehead flap side as it was on the scalp side so that one ends up with a 45-degree angle cut. The forehead skin laps over the cut edges of the scalp skin and, when that occurs, hair follicles grow right through the flap and scar" he says.

Dr. McCollough closes the incisions in the hair-bearing areas with stainless steel staples and places a small number of staples in the skin of the forehead before, running 5-0 plain catgut suture to further approximate the skin edges.

For best results, the closure, he explains, must be done under magnification, so that there is absolute apposition of the skin edges.

"The closure is key to getting a good scar--an acceptable scar. That is why we prefer and strongly recommend that others use magnification during the closure," Dr. McCollough says.


He puts a pressure dressing over the area to prevent bleeding and hematoma formation, and asks that the patient bathe the incision lines with hydrogen peroxide (if the patient has blonde hair) or with witch hazel (for darker-haired patients) about six times a day.

"If one is going to use absorbable sutures of the skin it is very important that you keep those sutures soft and moist and do not allow them to dry," he cautions.

Cheek lifts

Surgeons performing cheeklifts traditionally make the incision right in front of the ear, extending it straight up from the top of the ear and joining the incision from the forehead lift. "If you elevate the temple with that approach, the temple hairline goes up and back, as well" Dr. McCollough says.

"If a patient has a great deal of sagging, oftentimes that temple tuft of hair can be lifted an inch or two. Not only is that a problem in the primary lift, but it becomes a severe problem with subsequent lifting, where the temple hairline continues to elevate, creating a large non-hair-bearing area just above the ear."

The way to avoid that problem, according to Dr. McCollough, is to make the incision at the top of the ear and take it directly forward to the front edge of the hairline. Surgeons should do everything else in the traditional pretrichael, trichophitic fashion: They would cut across the hair follide then lay the flap over it and close it right under magnification.

"In the temporal area, too, the hair grows right under that scar and keeps the hairline in a normal position," he says. "You do exactly the same thing behind the ear. If the incision behind the ear is taken up into the hairline and you remove an inch or two of loose skin there, the hairline goes up an inch or two. The way to avoid that is to make the incision at the edge of the hairline, the pretrichael. If it is made in the manner where you cut across the hair follicles, which is what the trichophytic approach is, you leave the hairline where it ought to be and the hair growing through the scar helps camouflage it."

Other procedures

Dr. McCollough uses the open pre-hairline approach in most cases, but continues to rely on the other techniques from time to time. lust recently, he did the classic coronal forehead lift on a woman who had a very low hairline.

The open pre-hairline approach is catching on, according to Dr. McCollough.

"Everything in is an exchange. You trade one thing for another," he says. "In facelifting, the exchange is scars for loose, sagging skin. The challenge for the surgeon is to obtain the best surgical result with the least distortion of normal structures, including the hairline. The pretrichael, trichophitic approach to facelifting achieves this goal. Every time I go to a meeting and present this, I have more and more colleagues coming up to me and saying they have tried and like the technique. It is gaining acceptance all around the world."

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