A Comment on: Transfollicular subcutaneous forehead and brow lift

Funding: None
Conflict of interest: None
Clinical trial? No
Submitted on: 09/24/2025
Final decision: 15/10/2025
How to cite this article: Raimundo APA, Rezende HD, Dinato SLM, Bilia BM. A Comment on: transfollicular subcutaneous forehead and brow lift. Surg Cosmet Dermatol. 2026;18(1):e20260516.

Abstract

This correspondence comments on the recent article describing the transfollicular subcutaneous forehead and brow lift technique. Alopecia is a potential complication of such procedures, ranging from reversible telogen effluvium to permanent scarring forms. Although rare, hair loss can significantly affect patient satisfaction. Even minimally invasive techniques carry some risk. The transfollicular approach offers facial rejuvenation with hairline lowering, improvement of rhytids, and effective scar camouflage through preservation of anterior hair follicles. We emphasize the importance of transparent preoperative counseling and aim to enrich the discussion initiated by the original article.

Keywords: Alopecia. Dermatologic Surgical Procedures. Postoperative Cognitive Complications. Rhytidoplasty

A Comment on: Transfollicular subcutaneous forehead and brow lift

Abstract

This correspondence comments on the recent article describing the transfollicular subcutaneous forehead and brow lift technique. Alopecia is a potential complication of such procedures, ranging from reversible telogen effluvium to permanent scarring forms. Although rare, hair loss can significantly affect patient satisfaction. Even minimally invasive techniques carry some risk. The transfollicular approach offers facial rejuvenation with hairline lowering, improvement of rhytids, and effective scar camouflage through preservation of anterior hair follicles. We emphasize the importance of transparent preoperative counseling and aim to enrich the discussion initiated by the original article.

Dear Editor,

We would like to congratulate Gouveia et al. for their elegant and well-illustrated description of the transfollicular subcutaneous forehead and brow lift, a technique that combines aesthetic rejuvenation of the upper third of the face with safe dissection and excellent scar camouflage in the scalp.¹ By enabling lowering of the hairline, improvement of forehead and glabellar rhytids, and harmonious brow repositioning, this method represents a practical and innovative alternative to endoscopic approaches, particularly for patients with dense frontal hair. The emphasis on cost-effectiveness and technical reproducibility is another valuable contribution, making this procedure accessible in diverse clinical settings.

Nevertheless, we believe it is important to expand the discussion on postoperative alopecia in patients undergoing forehead and brow lifting procedures. While this complication is usually infrequent, the clinical spectrum of alopecia after surgical lifting is broader than often acknowledged, ranging from transient and self-limited forms to permanent and scarring alopecia.

In 2015, Kim et al. reported a case of localized telogen effluvium after rhytidectomy, with onset two months postoperatively and symmetric hair thinning along the incision lines. Biopsy revealed normal follicular density but an increased proportion of telogen follicles, with no peribulbar inflammation or scarring.² The patient experienced complete spontaneous regrowth within four months, without requiring treatment. This benign and reversible presentation contrasts with more severe outcomes described by Pham et al. in 2022, who demonstrated a significant association between facial surgical procedures—including rhytidectomy, blepharoplasty, and brow lift—and frontal fibrosing alopecia.³ In that cohort, nearly half of the patients with frontal alopecia reported prior facial surgery compared with fewer than 10% of controls, with an odds ratio of 7.8. Latency between surgery and alopecia onset averaged nine years, although cases were reported as early as three months postoperatively. The pattern and histology, when available, were consistent with lymphocytic cicatricial alopecia of the lichen planopilaris spectrum.

Furthermore, Cho et al. conducted a systematic review including more than 7000 patients and identified alopecia as one of the most frequent complications of brow lift techniques, with prevalence rates of 2.8% in the endoscopic method, 2.2% in the coronal approach, and 0.8% in temporal and lateral lifts.⁴ Although usually localized, alopecia in this context may still represent a relevant cosmetic drawback, especially in case of scarring or permanent hair loss.

The technique presented by Gouveia et al. is noteworthy for its careful incision planning. By angling the incision to transect follicles at different heights, some hair follicles are preserved, allowing anterior hair to grow in front of the scar, thereby providing effective camouflage. This refinement not only enhances the aesthetic outcome but also minimizes the risk of visible alopecia at the incision site.

Collectively, these reports emphasize the heterogeneity of alopecia presentations following surgical lifting procedures and highlight the need for vigilance regarding novel manifestations. Given the psychosocial impact of hair loss, this possibility should be discussed in detail with patients during preoperative counseling. Even though the risk is low, transparency about the potential for transient or permanent alopecia ensures adequate patient awareness and may improve satisfaction by aligning expectations with possible outcomes.

Once again, we commend the authors for their valuable contribution and hope this additional perspective may further enrich the discussion of complications in brow lifting surgery.

AUTHOR'S CONTRIBUTION:

Ana Paula de Araújo Raimundo
ORCID 0000-0003-0883-0474
Statistical analysis, Conception and design of the study, Preparation and writing of the manuscript, Acquisition, analysis and interpretation of data.
Hudson Dutra Rezende
ORCID 0000-0002-7039-790X
Statistical analysis, Conception and design of the study, Effective participation in the conduct of the study.
Sandra Lopes Mattos Dinato
ORCID 0000-0002-4547-0474
Statistical analysis, Approval of the final version of the manuscript, Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied.
Bruna Marques Bilia
ORCID 0009-0003-9550-5406
Statistical analysis, Acquisition, analysis and interpretation of data, Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied.

REFERENCES:

1. Gouveia AK, Loda G, Benez M, Loda AB. Transfollicular subcutaneous forehead and brow lift. Surg Cosmet Dermatol. 2025;17:e20250372.

2. Kim JH, Lew BL, Sim WY. Localized telogen effluvium after face lift surgery. Ann Dermatol. 2015;27(1):119–20.

3. Pham CT, Juhasz M, Ekelem C. The association of frontal alopecia with a history of facial and scalp surgical procedures. Skin Appendage Disord. 2022;8:13–19.

4. Cho MJ, Carboy JA, Rohrich RJ. Complications in brow lifts: a systematic review of surgical and nonsurgical brow rejuvenations. Plast Reconstr Surg Glob Open. 2018;6:e1943.