Hi!  I'm Dr. Epstein.  I am showing a hairline advancement procedure.  The patient has quite a bit of laxity which makes her a good candidate for the advancement procedure.

Her goal is to have her hairline brought down.  Right now it is approximately 10 cm, 9.5 cm above the eyebrows and the goal is to advance the hairline down by around 2 cm to 3 cm.  At the same time she is a good candidate for a brow lift so I am going to actually be at the same time doing some brow elevation.  She has already had a lower lid blepharoplasty.

The plan is to make the incision right along the hairline, wrapping around into the temple areas so I can get adequate redistribution of the dog ear or as the incision changes in direction get adequate closure there without bunching up.  This hairline is going to be moved forward while the brows are going to be brought up.  I anticipate being able to remove around this much of the forehead skin.

To facilitate the advancement, in addition to doing an undermining in the subgaleal plane all the way out to here, I am actually going to be cutting the galeal.  The galeal is just the deep layer that connects the frontalis with the  

occipitalis so we cut that just in two small areas to get more advancement.  You have to be careful in doing those galeotomies which are done in the coronal plane because they can de-vascularize the scalp.

What I am going to do first is as I said this is a nice showing of how loose she is.  When she is awake this sort of mobility was not immediately apparent because with most patients when they are aware they are holding their head up and it tightens the occipitalis and as a result the galeal tightens up as well.  But you can see, she is a very good candidate to have some good elevation.  Marcie, you are showing this, how the brow is moving back and forth?  You can see the amount of elevation.  We are going to do some brow lifting, bringing the hairline forward.  I anticipate that her hairline is going to go from here down to around here, coming right around like that.

Let's go ahead and we will start with the procedure, 15 blade.  Now she does have some rather crazy direction of hair growth so I am not really trying to follow that direction simply because it would be impossible to change my direction every time we do the incision in every area where the incision is made.  You can see, I am coming around like this.  Don't get too close Marcie.  You can see I am sort beveling that incision a little bit.

Marcie come from over here now.  I am going down to the galeal.  You can see I didn't do any excision of any hairs.  You can see this plane is very easily entered.  (Good.  Scissors.)

I'm doing her brow lift.  Usually there is a little bit of bleeding encountered over in the temporal area. (Good.  Hold this one up for me.  Good.  If one of you could just pull down a little bit here.  Pull up a little higher.  Down here please.  Very smooth.  Goes in very easily.  Actually take those away for a second.)  I can actually do a lot of this elevation just with a manual dissection.  You can see how I am doing this.

Posted by Jeffrey Epstein, MD, FACS