Dr. Houssock (00:04):
You are listening to another episode of Perfectly Imperfect. Alright. Hi Danielle.

Danielle (00:09):
Alright. Hi Dr. Houssock.

Dr. Houssock (00:11):
We have the director of the practice here today, everybody. How lucky are we? So welcome to the Perfectly Imperfect podcast. Danielle loves doing these, so she's excited to be here.

Danielle (00:23):
Love them so much.

Dr. Houssock (00:25):
All jokes aside, this is something new to our practice in the last year and everyone does such a great job, but it does take a lot of courage to be in front of the camera and really hearing your own voice. And so I give props to the staff because it's not an easy feat and they've really taken to it and the reason why they've taken to it so well is because they just like, I know that there's nothing better than knowledge and we want you to get to know us. And so that's why we do this.

Danielle (00:55):
Yeah. It's nice education for people before they come into the office.

Dr. Houssock (00:59):
Absolutely. Absolutely. Alright, so today we are working on or talking about hairline lowering and Danielle will tell you it's one of our niche procedures. Kind of talk everybody through because Dr. Vogel was doing this before I started the practice and then it became my niche from learning it from him. So talk about your beginning journey of how we started doing that in the practice Danielle.

Danielle (01:23):
Yeah, it mostly started from Dr. Vogel did a lot of hair transplants too. So we had a lot of people that started asking about lowering their hair hairline. And some patients needed it more advanced than just what hair transplant would do or they would need multiple sessions of a hair transplant to get them there. And so Dr. Vogel started doing hairline lowerings and it became actually pretty popular just like it is now where people fly in from even all over the country for it. It's not something that a lot of places do and that's just kind of how it started. And then when you came in it was pretty seamless.

Dr. Houssock (02:00):
It just made sense for our practice. So just to remind everybody, we do about 30% of our practice is hair restoration and hair transplant. And so there, that is a phenomenal surgery and it's been around for a really long time. But when you look at some of the patient population who are interested in hairline lowering or forehead reduction, it is generally speaking a very different population. It is a young female population. Most of the time they were born with a very high hairline or a large forehead. They come in and they joke, they have a five head. A lot of them, all jokes aside are really bothered by it and many of them come in covering it. They either wear a hairpiece or a wig, they wear headbands, they wear hats, and they spend their lives that way. They're really embarrassed by their high forehead. And really across the board, the vast majority are these young, beautiful women, they're gorgeous women.

Danielle (02:58):
Yeah, they are. Yep.

Dr. Houssock (02:59):
They really are, but they have a long forehead. And so what makes a high forehead? What does that even mean? So there is a little bit of science to this and it has something to do with what is called the aesthetic thirds. And the face is split into aesthetic thirds in both the horizontal and vertical plane. And when you look at the vertical plane, typically generally speaking, the thirds are your chin to the bottom of your nose, the nose to your eyebrows, and then your eyebrows to your hairline. And the most pleasing aesthetic face in the world, if you were to measure this, those women and men have the most harmonious thirds and so they're more similar to each other. So if for instance, the chin and to nose is something in the six range, then that would be the same here, six centimeters and then six centimeters.

(03:45):
And so when patients are bothered by their forehead, really it's the aesthetic third, the upper aesthetic third that is off it is longer than the other two thirds and that's what they're seeing. So there is no tried and true perfect forehead level, but I will say generally a female hairline is somewhere in the range of six to eight centimeters from the eyebrow to the hairline. But that's again, based on what is most common for the other thirds. The most harmonious face is going to be the most beautiful face. So whenever we're talking about hairlines, one of the worries should be is, well, you don't want to go too low. And that is true too because you could then bring that harmonious third into the wrong level, meaning you can go the other way where you're too low. So there is such a thing as too low, the hairline too.

(04:32):
And so when we see patients for forehead reduction or hairline lowering, it has to do with creating that more harmonious upper third. Now generally speaking, the reason why the population is so different is because really they're not the group that is losing hair. So they don't think to ask about a hair transplant because they never lost any hair. They just never had hair there. So I would argue that historically patients don't even think about themselves as hair transplant candidates because they don't think about this as a hair issue. They think about it as a forehead issue.

Danielle (05:13):
And that part of our practice too has changed a little bit. So between hair transplant and hairline lowering, who's a candidate for what? That has changed too in I feel like a really good way. So how do you decide who is a candidate for hair transplant versus hairline lowering?

Dr. Houssock (05:30):
Right, so someone will call in and really we always have to be kind of ready to speak about either because it may or may not be one or the other. So generally, and this is very generally, the hair transplant patient is typically the male patient. And the reason why I don't like talking hairline lowering is because, we will talk about this momentarily, but one of the things that you have to do when you do a hairline lowering surgically is put a scar at the hairline and a male is more common, much more common to over their lifetime, have hair recession and wear that scar might be completely hidden at the time of their hairline lowering as they age, that scar could become very, very visible as they lose hair behind that scar. So I don't offer the surgical hairline lowering to a male patient for that very reason, where females though we have a risk of losing hair throughout our life, were less common or less likely to lose it in the recession way, meaning losing it from the front back.

(06:32):
So those patients are much safer to do a hairline lowering. And they have oftentimes the women who come in their hair is so thick behind their hairline, meaning that they've never lost hair. So they have this beautiful, thick full hair behind the hairline, it's just too high. And if we try to transplant that patient, if they have really thick hair behind and they don't hair loss, the hair transplant's always going to be lighter than the hair behind it. So for most patients, and again there's a caveat that we'll get to in a second. So for women generally who have a high forehead who have not had hair loss and have really thick full hair, they're always going to be best to be treated with a hairline lowering where we surgically bring the forehead down and we'll talk about that in a second. The men who have a high forehead, they are much more likely to be geared towards a hair transplant because if I transplant their hairline and I make their hairline lower by using transplant, then even if in the future they have some recession, it's a lot more natural of a look to lose your hair over time.

(07:40):
And we certainly can account for that in our surgical plan when we do the transplant. So for men, hairline lowering is in the form of hair transplant. For some women, and this is the caveat we're about to get to for some women, hairline lowering is the best. The caveat is that over the years I've found that patients with really thick curly hair who are just phenomenal hair transplant patients, I have geared those females to also having hair transplant over a hairline lowering. The reason for that is in the end, with a hairline lowering, you do buy a scar at your hairline. And so with every hairline lowering surgery patient in our consultation we discuss that it's possible you may need a second stage hair transplant into that hairline. So for that patient population who has a super curly, beautiful thick hair that I know transplants really, really well, I will often tell them that their result in one stage, meaning just hair transplant may be optimum to them going under the knife and having me do that hairline lowering. And we have patients, this particular patient we're showing here on the video now is one of those patients, she came in with a hairline lowering plan, that's what she wanted. We talked about how beautiful her hair it is on its own and how I think that she would really benefit from just transplanting from the front. And so she had hair transplant and so there is a patient population now, a female patient population that even though they're coming in expecting to possibly talk about hair line lowering, they may be geared towards hair transplant.

Danielle (09:21):
And then they save that scar and all of that recovery and they've been having amazing results with that. Yeah.

Dr. Houssock (09:30):
Yes. For the patient population who is a general, someone who has hair like my own thin, but a lot and straight hair, I am a really great hairline lowering candidate if my forehead was higher. So for that patient population with a thinner hair that is straight hasn't had any significant hair loss in their life, but they just really do not like their hairline, they would be best for the hairline lowering. The way that that works, the process is that I make an incision and that there is a stop point. There's an anatomical stop point where I will do it. I make the incision right along the hairline and it's not in the hairline. There is some trickery out there with advertising about don't worry about your scar, it'll be hidden in your hairline. It can't be in your hairline because the way that this surgery works is right at the front of your hairline is where we make the incision and then the entire scalp is lifted off of the skull.

(10:23):
It's a little bit morbid I must tell you. And so once we release you and really scalp you off of your skull, then it gets pulled forward and tacked, and the skin in the front of your forehead gets removed. And so the hairline just gets pulled right down and the skin gets excised at the hairline and that's how we bring the hairline down. And you do, you wake up with an immediate lower hairline. We can typically get somewhere around two centimeters. And that doesn't sound like a lot, but that is a lot when it comes to a hairline, if you take somebody from an eight to a six or a nine to a seven, they go immediately harmonious. The face does not need big movement to make big changes. So generally speaking, you wake up with a lower hairline, but you are waking up with a scar along that hairline.

(11:12):
And for some women that scar heals beautifully and invisible, and for some it doesn't. And there's a lot of factors that go into that. Some of it has to do with your genetics, some of it has to do with how you scar, some of it has to do with how you take care of it. And so for all those reasons, I always tell patients in consultation, we don't know how your scar is going to look once you're healed. And so please understand that if you are going forward with a hairline lowering, you are buying a scar on the front of your face for the rest of your life. It's really important to know that, we can never promise an invisible scar. The good news is is that Danielle and I work in a practice and have a practice where we do hair restoration. So even if you have the worst scar, we can camouflage that scar moving forward with a hair restoration, second stage hair transplant.

Danielle (12:04):
And I always give them the quote for that right away. I give a quote for the hairline lowering and a second stage transplant. So it's very transparent of what that would cost.

Dr. Houssock (12:14):
That's just it, we do not want there to be a surprise. We are not here to try to trick you into anything we want you to understand and know what you are diving into. And so Danielle will always give two quotes at that consultation so that we are very open and upfront. And if you don't need that second stage, great, your scar is done, it's beautiful, you're happy. You're not having to commit to that second stage, but we want you to be very aware that there is a chance you'll need it or want it.

Danielle (12:40):
What do you think that percentage is that people that do that second stage or need that second stage?

Dr. Houssock (12:46):
30%? 30% I would say.

Danielle (12:48):
That seems about right.

Dr. Houssock (12:50):
Yeah. Now there are two reasons why you might want that second stage for somebody whose hairline is starting at 10 or 11 centimeters. Remember I said that a women's hairline is somewhere between six and eight centimeters. So if you're starting at 11, I'm only going to get you to nine with that hairline lowering. So there is a patient population where then, and I'll tell you this at consultation, you will need that second stage to really make you most harmonious. So we would take you to 11, from 11 to nine with your hairline lowering and then with transplant that last two centimeters of nine to seven. So there is a group that Danielle and I will say, listen, for some people the second stage is a possibility for you if to get the harmony that you really need, it will be mandatory. And those patients, this particular patient here that is now on screen is one of those women, she started really high with her hairline. She then had her first stage, which was the hairline lowering, and then second stage, several months later we did a hair transplant and then she now looks harmonious. So it really is based on your anatomy whether or not you'll need that second stage

Danielle (13:55):
And you wouldn't do a hair line lowering twice on somebody, right, because of the scalp laxity?

Dr. Houssock (14:00):
Right. Totally. And so one of the other reasons why we can only get about two centimeters is the scalp only has so much laxity and if you try to push it too hard and go too tight, your scar won't heal well or it might not heal at all. And so we go with what your scalp can give us. And generally we've been doing this a long time, it can give about two centimeters. If it can give more, amazing. I've gotten people who were able to be brought down to three centimeters but, three centimeters down, but that being said, I don't promise it because it's not typical. So if someone comes in and their hairline is eight centimeters and we're going to bring them down to six, that's great. They probably won't need that second stage unless their scar is not amenable to good camouflage. It depends on so many different things, whether or not you'll be that person, which again is why we're so open about the fact that this is a big scar and you may or may not be able to camouflage it well without a second stage.

Danielle (14:56):
Important question, recovery from hairline lowering?

Dr. Houssock (15:00):
Yeah. So we're really sticklers about this because we know the scar is so obvious. It's right on the front of the hairline. We see you a lot. So we see you at 48 hours a week, two weeks, four weeks, three months. We see you a lot. And the reason is I want to make sure that you are healing beautifully. I want to watch that scar. You go home with a very specific plan for how to take care of your incision as it heals. We're really strict about smoking and alcohol use just like we are with every other surgery. But even more so with the hairline lowering, we do ask that you lay low for a good four weeks. So for four weeks you're just doing light activity. It's not a painful procedure, interestingly, the reason why is where we cut cuts temporarily, the nerves that feed the scalp.

(15:47):
And so patients don't complain of pain. What they complain about is a little bit of pressure, but mostly numbness. It feels weird for a while when you touch the top of your head when you're itching or when you're doing your hair. The numbness there is very, very obvious. And so that does come back in the vast majority of patients, but it can take up to a year or more for that to happen. And it's the one thing that patients mention is that they still feel numb, but the vast majority of patients will get their sensation back. There is always a risk that you may not, but it's very, very unlikely.

Danielle (16:20):
And because we do have a lot of out-of-state and out of country patients that fly in for this, how long do they need to stay in town?

Dr. Houssock (16:27):
So we do get people to travel to us and I do ask that you stay at least a week. I would like you to stay for two because I take your sutures out at two weeks. So some patients will leave and come back for that. We can have someone else take out your sutures, but I really hate that because I just feel that I really want to be the one touching that incision the first few weeks. But we do make it work. We've made it work. But I would say the vast majority of patients will stay at least a week. And some of them will come back for their second week and have me take their sutures out.

Danielle (16:59):
Any reason you wouldn't do a hairline lowering and hair transplant at the same time?

Dr. Houssock (17:05):
Yeah, because there's so much, so many moving parts and ultimately when you're doing a hairline lowering, you're going to have an incision and that incision is going to be the one place that if you need a hair transplant, you're going to need a transplant into and you're just doing a disservice to the follicles, I think to not let it really settle and let it do what it needs to do, see where the hairline is, see how you heal. The grafts are going to be much more likely to live if they've got a bed that is stable. So I wouldn't do it at the same time. It does have to be staged if you need it, if you need it. Again, it's not everybody. What I was finding is that my patient population with thick curly hair, African-American women who have beautiful thick, dense hair, we were having an issue with them is that their scars typically aren't the best.

(17:54):
They're not the best scars, they are more likely, not always, but they're more likely to have hypertrophic scarring. I've never had a keloid scar in that area, but it certainly would be a risk. And so a lot of my African-American women were going through hairline lowering and then needing that second hair transplant anyway because they either were too high to do in just hairline lowering or their scar wasn't great. And so the more that I have practiced and the more that I've done, I find that even in the highest forehead, even in the high ones, and I'll show a picture of one here where she had a long way to go doing a hair transplant on her alone was so successful she didn't have to worry about the risk of that scar. And her hair is so valuable and wonderful and thick that when we transplanted her, her coverage was so beautiful just on its own that I find myself, again, gearing that patient population to doing transplant only.

(18:53):
No one has regretted that yet. They always are leery. Yeah, because it's a stigma. When we think hair transplant, we think that's men, white men, it's usually white men. We think about the commercials and I'll tell you in our other podcast if you listen to them, when we talk about hair transplant, our patient population is not just white men. We see everybody. And the fastest growing portion of our practice with hair restoration, hair transplant is women and transitioning women. So yes, we do a ton of male hair restoration and everyone comes to the table with something different and has success, but generally speaking, someone with a thick curly hair is going to just be so good for transplant. So again, that might be the patient population, though they may want a hairline lowering, they may end up leaving the practice with a hair transplant

Danielle (19:47):
And they've all been very happy with that, yes. And they can do it more than once if they need to for density or to lower it down the line. But yeah.

Dr. Houssock (19:57):
So what it comes down to is hairline lowering is one stage. You wake up with a hairline that's lower in one stage and it's immediate. And so that is attractive to people.

Danielle (20:06):
You don't have to wait for the hair to grow in.

Dr. Houssock (20:09):
But with that is a caveat of a permanent scar, that might need to be camouflage with hair transplant. Conversely, you've got the other side, which is the patient population who we transplant and we say this might be done in one stage, but you also may want, and we tell every hair transplant patient this, you may want a second stage for density. You may want, once it grows in, you may want more hair. And I wish everything we did was just one and done, but that's just not how life works.

Danielle (20:34):
Right. Nope.

Dr. Houssock (20:35):
It just isn't.

Danielle (20:36):
And we like seeing our patients so we're happy about it.

Dr. Houssock (20:40):
Yeah, yeah. But we get the inconvenience of hearing, hey, you might need a couple stages, but there's nothing worse than not being prepared. And so we're really sticklers for that. I don't know, I think we did a good job of explaining it.

Danielle (20:52):
I think so. Obviously any questions, always people call, always send an email, anything happy to virtual consults for this because it is, like we said, most of our patients do come from far away, so we do offer virtual for this surgery.

Dr. Houssock (21:11):
Alright, Danielle, carry on.

Danielle (21:12):
See you next time. Carry on.

Dr. Houssock (21:14):
See you next time.

(21:14):
Perfectly Imperfect is the authentically human podcast navigating the realities of aesthetic medicine. JEV Plastic Surgery is located in Owings Mills, Maryland. To learn more about us, go to JEVplasticsurgery.com or follow us on Instagram @DrCareHoussock, spelled D-R-C-A-R-E-H-O-U-S-S-O-C-K, or just look in the show notes for links. If you enjoyed this episode, please share it and subscribe to Perfectly Imperfect on YouTube, Apple Podcasts, Spotify, or wherever you'd like to listen to podcasts.