Hair and Hairline
Many FFS surgeons and patients believe that on average, women have lower hairlines in the middle than men but this is not actually true. In fact, women have higher hairlines in the middle than men (you can read more about this towards the bottom of the page under "Misconceptions").
Of course men often get male-pattern baldness which can raise the hairline, and some men have naturally high hairlines. But the average male hairline, when balding is not present, is lower in the middle than the average female hairline.
If you look at the corners of the hairline the situation is reversed with women having lower corners and men having higher corners. The high corners and low middle of the male hairline tend to give it an M or square shape, while the low corners and high middle of the female hairline tend to give it an inverted U shape - ∩
Here is an animation created from averaged male and female faces showing the lower hairline at the front in the male:
You will see the same differences in other examples of averaged faces on the internet. A good example is the BeautyCheck website. You can also see more of them in part 3 of my thesis on facial feminisation here.
To sum up: most trans women do not need to bring the whole hairline forwards, they only need to fill the corners.
Surgical Options for Filling the Corners:
1. Scalp Advance:
Some surgeons try to fix the corners with a scalp advance which involves cutting along the hairline and stretching the scalp down in various ways to try to fill the gaps. I have seen little evidence that this is an effective technique and it always leaves a scar along the hairline.
2. Hair Transplants:
Hair transplants look more natural than a scalp advance and you don't end up with a scar along the hairline. They would normally be done a few months after any forehead surgery. Facial Team have developed a way of doing them at the same time as forehead surgery by harvesting a strip of scalp from the incision they use to do forehead surgery. They are then able use the hair follicles from that strip to fill the corners. See below for more on hair transplants and how they work.
In the minority of trans women who have naturally high hairlines or who have male pattern baldness affecting the hairline height, it might also be appropriate to lower the whole hairline.
Surgical Options for Lowering the Hairline:
1: Scalp Advance:
In a scalp advance a strip of skin is removed from in front of the the hairline, the scalp is lifted away from the skull and pulled forward to fill the gap. There is a limit to how far the scalp can be moved in one go - an inch or an inch and a half (2 to 3 cm) is typical so two or more separate scalp advances several months apart may be required to achieve the desired result. If the surgeon is also doing work on the forehead bones, they can do it through the same incision as the scalp advance.
However, There is always a visible scar from a scalp advance. How visible it is will partly depend on luck, partly on the skill of the surgeon and partly on your own tendency to scar. Some patients with a faint scar feel that it is not a problem, but for many others, it is clearly visible and they are conscious of it.
Here is a photo of a scalp advance scar that someone was kind enough to let me use. This one is a little worse than average but you can clearly see the problem:
2: Hair Transplants:
You can also lower the hairline by using transplants. This leaves a much more natural-looking hairline with no visible scar. The transplants would normally be done a few months after any forehead surgery. See below for more on hair transplants.
Some people combine both procedures - they start with a scalp advance during their forehead surgery, then a few months later, they finish the hairline and fill the corners with transplants. This can be useful in cases where the hairline needs to come forwards quite a long way.
I had 2 sessions of hair transplants with Dr Damkerng Pathomvanich in Bangkok, Thailand. Here is a close-up of my hairline so you can see how they look about 4 years on. The front centimetre or so is all transplants:
About Hair Transplants:
Hair transplantation involves taking hair follicles from one part of your scalp and transplanting them into another part where hair is thin or missing. In the past, the technique gave poor results because large clumps of hair (sometimes called "plugs") were transplanted giving an effect a little like doll's hair. Modern techniques though are excellent, transplanting a single follicle at a time and giving an invisible result when done by a skilled surgeon.
Modern transplants fall into 2 categories:
This stands for "Follicular Unit Transplant". This is where a strip of scalp is taken, usually from the back of the head. The hair follicles are then dissected out before being transplanted into the problem areas. My transplants in the picture above were FUT.
This stands for "Follicular Unit Extraction". This is where individual hair follicles are removed one at a time from various places around the scalp and transplanted into the problem areas.
With FUT you can transplant more hairs in a single session, the hair follicles are less likely to be damaged and it is generally cheaper. However, there is a linear scar at the back of the head which could show if you had very short hair.
With FUE the recovery time is shorter, there is no linear scar, and you don't need such a big team of people working on you. But, it is more expensive, you can't transplant as much hair in one go, and there is a greater risk of damaging the follicles.
Each hair follicle contains between 1 and 4 hairs. The transplanted hairs fall out soon after transplantation but the hair follicle is alive and about 3 to 4 months after the surgery, the hairs start to grow again.
There is a limit to how densely the hair can be packed in at one time so more than one procedure may be needed to achieve a good density.
Does a scalp advance cause permanent numbness?
Not if it is done properly with the surgeon taking care to avoid the key nerves. There will certainly be some temporary numbness, but this should disappear over the course of a few months.
Will my hairline be raised if I have the incision for forehead surgery over the top of my head?
Yes, but only slightly, and as women tend to have slightly higher hairlines in the middle than men, this can actually be mildly feminising. And you also have the advantage of the scar being hidden.
Should a scalp advance always be avoided?
No, sometimes, for example when the hairline is very high, it can be a useful procedure, but be aware of the visible scar problem and prepare for a session of transplants to hide it.
What if I need a forehead lift with the incision along the hairline?
For some patients who have fairly high hairlines but who also need a forehead lift, it might be necessary to put the forehead lift incision along the hairline. This is normal, but be aware that there will be a scar so you might want to cover it with transplants a few months later (A forehead lift is where the eyebrows and all the soft tissues of the forehead are lifted for a rejuvenating and sometimes feminising effect).
Can a scalp expander help?
A scalp expander is an inflatable balloon that is placed under the scalp and gradually inflated over a few weeks so that the scalp will stretch further. This is quite an invasive technique and can be painful. There is also an infection risk because you have an open wound for the duration that you have the expander in.
I do not know of any advantage to using an expander (except perhaps that it is cheaper) and I do not recommend the technique.
My Surgeon uses a special incision that makes the scar invisible:
It is possible to angle the cut so that the hairs will grow through the scar tissue to some extent. This helps to hide the scar, but it does not make it invisible.
Misconceptions About Hairline Height:
So why do so many people believe men's hairlines are lower overall? There could be several reasons - male pattern baldness is quite common so in that respect we are used to seeing cases of men with high hairlines and we generally don't see that particular type of recession on women. Secondly, men's hairlines are higher in the corners and maybe we notice that more than the height in the middle. Then again, it might simply be a myth that has gone around for no apparent reason.
The fact that many patients and surgeons believe it to be true is a big problem because it can lead people to have surgery to move the whole hairline forwards when they don't need it and when, in many cases, it can actually have a masculinising effect. It also leaves them with a scar along the hairline which in many cases is clearly visible.
For the majority of faces I work on, the height of the hairline in the middle does not need to change – I only need to fill in the corners of the hairline to give it a rounded female shape.
You can read more about hairlines in Part 1 of my Facial Feminisation Thesis but I can sum up my approach to hairlines with this simple rule:
The shape of the hairline is more important than the height!