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What is the difference in doing a browlift in front of the hairline vs. in the scalp?
There are several indications for hairline incision. For instance, if the patient has a long forehead and the incision in the scalp will lengthen the forehead even more making the patient look odd, then it is better to have a hairline incision; in addition, if a forehead reduction and a scalp advancement can be performed at the same time. Some surgeons believe that hairline incisions result in less scarring and are easier to camouflage in appropriate patients. You can be assured that an incision in your scalp will also leave a scar.
An incision at the hairline is appropriate if you have a high forehead and wish to reduce it. This allows one to remove some of the forehead skin, thus making the distance between the eyebrows and hairline less. A long incision behind the hairline is an antiquated operation and almost never used today. Instead, we use small incisions behind the hairline and, usually, an endoscope (lighted tube with camera). Even with the pre-hairline incision I only remove the skin and use an endoscope for releasing the brow. This preserves the sensation of the scalp.
If you have a high forehead, then YES.
If you want to have a certain technique like a subcutaneous browlift, then YES.
Hairline incisions do leave scars BUT they also usually heal quite nicely where your hair covers it quite well and it is inconspicuous. You should thoroughly discuss this with your surgeon that you choose to do your procedure for you.
Actually the traditional advice of using a pre-hairline incision in patients with a high forehead does not always hold. In some patients with a high forehead and sometimes even in men with a receding hairline, one can still perform an endoscopic procedure with incisions hidden above the hairline because if the lift is done at a level that goes beneath the periosteum, then the distance between the brows and the hairline remains the same as the entire unit is lifted in continuity, even though the hairline is technically higher. So, it will still look normal as the distance between the brow and hairline is unchanged. A subcutaneous lift will definitely increase this distance and the hairline will look excessively high.
Subperiosteal endoscopic browlifts are very forgiving in terms of this issue although it is better in vertically oriented foreheads as opposed to rounded ones. It is good to avoid pre-hairline incisions in most patients unless they have hyperactive frontalis muscle syndrome with a rounded high forehead. In those patients one can perform an endoscopic biplanar technique with a pre-hairline incision.
When doing a brow lift in front of the hairline, it gives a more predictable result as well as a more direct lift of the brow. The down sides include that it can have a potentially visible scar and may shorten the forehead.
The advantage of a scalp incision is that it is less visible, but is slightly less predictable than the direct hairline incision. Furthermore, it can elevate the hair line, which may be desirable for someone with a short forehead. However, for someone with a longer forehead, this may be undesirable.
I would encourage you to read a little bit more about an endoscopic brow lift (using cameras) which has tiny little incisions in the hairline.
Hairline vs. Scalp Lift – A hairline brow lift is a procedure performed on patients that have ample hair, but have a high or long forehead. For this type of patient, it is a very good operative procedure. A transcoronal browlift is done on patients who have deep frown lines and a normal brow height. In general, these operative procedures are only reserved in these situations. Most of the time, I perform a minimally invasive, endoscopic brow or and endotemporal browlift.