Guide to Hairline Feminization and Facial Feminization Surgery

At Facial Feminization Surgery we realize that many factors may be involved in facial feminization surgery (FFS, a type of gender confirmation surgery), and that these need to be determined on a case by case basis to address each patient’s unique needs. For many patients, however, the most important area in facial feminization surgery is the forehead region and hairline.

We often receive requests for additional information on hairline feminization procedures, so we have put together this guide to the most important considerations in hairline redefinition, the different methods that may be used, and how hairline feminization should be timed in conjunction with other facial gender confirmation surgical procedures. Years of experience in facial feminization surgery have led us to the following conclusions.

Aspects of successful hairline feminization

The primary goal with hairline feminization procedures is to achieve a feminine yet natural-looking result. To achieve this, we must consider not only the shape of the hairline, but also its placement, irregularity, density, and the patient’s unique facial features.

Prototypical female and male hairlines and The Lipuhai Rule. Prototypical rounded feminine hairline (left) and M-shaped masculine hairline with peaks and recessions (right). The Lipuhai Rule measures the distance between the interpupillary line and the intercommissural line and applies that distance to the upper third of the face. This distance typically marks the hairline in men, while in women it is slightly below the hairline. Courtesy of Alexandra Hamer.

A typical female hairline is rounded, while male hairlines are typically M-shaped, broad and flat at the top with a central peak and two lateral recessions.  Hairlines that are too low or close to the eyebrows are masculinizing and artificial-looking, while hairlines that are also undesirable. Irregularity is necessary for a natural result – no natural hairline is perfectly even, male or female. The density of the hair (number of hairs per unit area) is more important than the amount of surface area being covered. If the follicle density is not correct, sparse areas of the hairline can yield unsatisfactory results. Sometimes a second transplant is necessary to achieve the desired results.

Because every patient is unique, it is essential to develop personalized solutions based on their specific case (shape and recession of hairline, peak width and depth, other areas with thinning hair, etc.) and the patient’s desires and expectations.

Who is a good candidate for hairline feminization?

Patients who have hairlines with a masculine shape are candidates for hairline feminization, provided they have completely stabilized any balding (usually accomplished with hormone therapy) and meet specific criteria depending on the procedure best suited for them. This is important in order to meet the patient’s expectations and to maintain a desirable hairline during the patient’s lifetime. Patients should allow adequate healing time between hairline procedures and other surgeries, if applicable, and schedule accordingly.

Hairline feminization through hair transplants requires that certain additional criteria be met, including hair density and follicle quality. This is the most common method used to redefine hairlines and is indicated for the majority of patients seeking hairline feminization. Hair follicles may be obtained for grafting either in a strip (FUSS “Follicular Unit Strip Surgery” technique) or one by one (FUE “Follicular Unit Extraction” technique).

Approximately 1 in 20 patients will be a good candidate for a scalp advancement surgery (surgical lowering of the hairline) instead of hair transplants. These patients will already have a rounded shape to their hairline (without peaks or recessions), but the hairline will be excessively high. This method carries a risk of visible scarring and of creating a hairline that is too low in the center (more typical of a masculine hairline).

Scalp advancement surgery to lower the hairline is only recommended in patients with excessively high hairlines which already have a rounded (feminine) shape.

*All patients have the possibility of needing a second session of hair transplants to achieve the desired results, especially to increase hair density in thinning areas or to fill in large recessions. A hair transplant specialist would assess the results of the first procedure to determine if a second session is recommended.

When should hairline feminization take place relative to other facial surgeries?

Follicle transplants may be performed before or after other gender confirmation surgeries, and in some cases can even be performed at the same time in a single surgical procedure:

  • Before: Hair transplants should be given at least 12 months to heal and establish themselves before undergoing other surgeries like forehead reconstruction. Follicles may be obtained using either the FUSS or FUE technique.
  • After: Previous bone remodeling procedures should be allowed to heal for at least 6 months before undergoing hair transplants. Follicles may be obtained through FUSS or FUE.
  • During: In the case of a forehead remodeling surgery using the coronal approach, a hair transplant may be performed simultaneously (FUSS technique). The incision made at the crown of the head for this surgery removes a small strip from which hair follicles may be grafted into the hairline. Depending on the number of follicles obtained, the simultaneous remodeling and hairline redefinition has the benefit of complete feminization of the upper third of the face. The coronal approach also eliminates the problem of visible scarring and provides a slight elevation of the brows, creating a more feminine appearance.

Final words on hairline feminization procedures

If you are considering hairline redefinition in the context of facial feminization surgery, we hope you have found this guide useful. A successful hairline feminization is a complex art and science and is constantly evolving.

We have always believed in establishing parameters that allow us to take an individualized approach to hairline solutions in order to determine the best treatment options for each patient.

On behalf of our Research & Development Department and surgical group, I am pleased to announce that our detailed clinical conclusions on the subject of individualized hairline feminization solutions are pending publication in a prestigious medical journal.

We welcome any questions, comments or contributions you may have.

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