Temporal Hairline Research Articles

Dizziness and Pain After Temporal Augmentation With Hyaluronic Acid.

Hyaluronic acid is a commonly used soft tissue filler. However, it has been associated with numerous complications including skin necrosis, loss of vision, and cerebral infarction. In this article, the authors have reported the case of a 25-year-old woman who presented with significant dizziness and pain in the temporal and intrahairline region after undergoing hyaluronic acid augmentation of the temple and inner temporal hairline regions. Subsequently, the patient received 4 doses of a hyaluronidase injection to dissolve the emboli. She demonstrated improvement in clinical symptoms after emboli dissolution. During the 10-month posttreatment follow-up, the patient experienced gradual relief from pain and dizziness. The use of hyaluronic acid fillers should be limited in the intrahairline region as the resulting complications can be difficult to manage.

Reconstruction of the Defect at Temporal Hairline by a Scalp Keystone Island Flap: Clinical Experience on 14 Cases.

The reconstructions of defects at the temporal hairline always require more complicated designs and higher surgical skills to acquire better aesthetic results. By taking advantage of the unique anatomy of the temporal region, the authors designed a scalp keystone island flap pedicled by superficial temporal fascia to repair defects on the temporal hairline. The authors retrospectively analyzed the clinical data of 14 patients who had lesions adjacent to the temporal hairline between April 2018 and June 2020. Patients were diagnosed with basal cell carcinoma, squamous-cell carcinoma, or seborrheic keratosis. These lesions were resected and reconstructed by scalp keystone island flaps. The defects ranged from 2.0 cm × 1.5 cm to 3.0 cm × 3.5 cm. All patients were satisfied with postoperative morphology and reported no recurrence at the 6 to 24 months follow-up. Flaps in two patients were partially necrosed but eventually healed by dressing changes. The rest had the first intention of healing. The scalp keystone island flap is a very useful method to repair small or medium defects at the temporal hairline. This flap can be flexibly designed and easily performed with a high survival rate and good aesthetic results. It provides another surgical option for complicated reconstruction.

Frontal fibrosing alopecia: survey of severity assessment methods in routine clinical practice and validation of the International Frontal Fibrosing Alopecia Cooperative Group measurement guidance.

The lack of validated and responsive outcome measures in the management of frontal fibrosing alopecia (FFA) significantly limits assessment of disease progression and treatment response over time. To understand how FFA extent and progression is currently assessed in UK specialist centres, to validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and to identify pragmatic advice to improve FFA management in clinic. Consultant dermatologists with a specialist interest in hair loss (n = 17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images (Questionnaire 1), with assessment repeated 3 months later to assess intraindividual variability (Questionnaire 2) and 12 months later to test whether interindividual accuracy could be improved with simple instruction (Questionnaire 3). All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques used by our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement [intraclass coefficient (ICC) = 0.61; 95% CI 0.40-0.85], yet intrarater reliability was found to be poor with wide limits of agreement (-8.71 mm to 9.92 mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (Questionnaire 3), inter-rater reliability improved significantly, with ICC = 0.70, suggesting moderate agreement (95% CI 0.51-0.89; P < 0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction. We found that accuracy of measurements in FFA can be improved with simple instruction and we have validated components of the IFFACG measurement recommendations.

A novel technique for forehead and eyebrow reconstruction using a temporal hairline flap combined with a free forearm flap: a report of two cases.

We herein report a novel technique for managing large forehead skin defects that include the eyebrows and upper eyelid. Case 1 was of a 55-year-old woman with an eccrine carcinoma (T2N0M0) at the right forehead, resulting in a skin defect 15 cm in diameter. Case 2 was of an 81-year-old man with a malignant peripheral nerve sheath tumor (T1a N0M0) at the left forehead, resulting in a skin defect 18 cm in diameter. A pedicled temporal hairline flap and free forearm flap were combined and placed on the defect, and good eyebrows and forehead morphology was ultimately achieved.

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Eyebrow Reconstruction With Temporal Hairline Relay Flap.

Eyebrow is one of the most important features of the face; the absence of eyebrows will cause a heavy psychological burden to patients. Existing brow reconstruction techniques are not perfect for every case of eyebrow defect. In this study, a patient who suffered from eyebrows loss after radiotherapy for hemangioma underwent eyebrow reconstruction with the relay transfer of a temporal hairline flap. The entire procedure was performed in the outpatient operating room. The temporal hairline flap was transferred to the eyebrow region in a relay and survived well without necrosis. In the 2-month follow-up, the shape and density of the reconstructed eyebrows were satisfactory. The operation showed this technique was innovative, economic, and recommended as a suitable choice for eyebrow reconstruction, especially in those patients with poor hair transplantation recipient area.

Study of Frontal and Temporal Hairline Patterns in Japanese Subjects.

Background:The shape of the hairline is very important in a person’s identity and in determining the impression they make. Reports on the morphology of a normal hairline are still scarce. Differences in the shape of male and female hairlines in Japanese subjects are discussed in this study.Methods:A questionnaire about hairline type, the presence or absence of a widow’s peak, and measurement of the width and height of the forehead was given to 456 healthy subjects, and their responses were recorded.Results:Percentages of frontal hairline types were found to be linear (women 36.1%, men 45.9%), triangular (7.2%, 0.82%), round (38.5%, 10.7%), and M- shaped (18.2%, 42.6%). Temporal hairline types: inverted triangle (20.3%, 65.6%), inverted round (27.8%, 17.2%), straight (24.8%, 10.6%), and convex (27.2%, 6.6%). The incidence of a widow’s peak was 29.6% in women and 32.8% in men. The mean length of the mid-frontal line was 6.2 cm in women and 6.65 cm in men.Conclusions:Regarding the hairline morphology of the frontal view, two types (linear and M-shaped) accounted for 88.5% of men. In women, linear accounted for 36.1%, being relatively high, but lower than the frequency in men. Round accounted for 38.5%, being the highest. Regarding the temporal hairline, a hairless region (inverted triangle and inverted round) was noted in 82.8% of men. In women, a hairless region was present in 48.1% and was absent (straight and convex) in 51.9%. A temporal hairline with a hairless region was noted in the majority of men, whereas it was absent in slightly more cases in women.

Temporal augmentation using autologous fat grafting in Chinese women: Effect on temporal hairline.

Temporal hollowing causes an old and gaunt appearance. An inward curve of the temporal hairline adds to the severity of temporal hollowing, which is visually exacerbated by the dark-colored hairline in most Chinese women. Whether temporal augmentation using autologous fat grafting (AFG) is effective for correcting an inwardly curved temporal hairline remains unclear. To assess the effect of temporal augmentation using AFG on the temporal hairline. Forty-six women with an inward-curved temporal hairline, who underwent temporal augmentation using AFG, were recruited. The preoperative and postoperative severity of temporal hollowing was evaluated, and anthropometric measurements regarding the temporal hairline were performed on photographs taken in the frontal and lateral views. Subject satisfaction and incidence of complications were documented. A slight increase in forehead width was observed. The minimal forehead width and minimal forehead width/forehead width ratio were increased. The width, depth, and height of the temporal peak were all increased as well, indicating that the previously inwardly oriented temporal peak was shifted slightly outward, upward, and backward after augmentation. Autologous fat grafting satisfactorily smoothened the temporal hairline without excessively increasing forehead width in subjects with temporal hollowing and an inward-curved temporal hairline.

Diagnosis of Sertoli-Leydig Cell Tumor of the Ovary Complicated by the Pattern of Hyperandrogenemia and Results of Imaging

Introduction: Virilization in a postmenopausal woman requires evaluation for an androgen-secreting tumor. The differential diagnosis includes adrenal carcinomas and adenomas and Sertoli-Leydig cell tumors, granulosa-theca cell tumors, and hilus-cell tumors of the ovaries. We present a case of virilization in a postmenopausal woman caused by a Sertoli-Leydig cell tumor (SLCT) in which evaluation was complicated by the pattern of androgen elevation, bilateral adrenal nodules, and absence of an adnexal mass. Case: A 64-year-old female was referred for evaluation of hyperandrogenism. Hirsutism, temporal hairline regression, and unusually deep voice were noted on examination. Two total testosterone levels obtained one month apart were 146 ng/dL (2-45), and measurements of dehydroepiandrosterone sulfate (DHEAS) and androstenedione were 299 mcg/dL (12-133) and 1.84 ng/mL (0.130-0.820), respectively. Abdominal CT revealed bilateral adrenal nodules - 2 cm and - 5 Hounsfield units (HU) on the left, and 1.5 cm and 5 HU on the right - but no ovarian masses. Transvaginal ultrasonography also failed to identify a discrete ovarian mass but showed endometrial hyperplasia. Virilization, magnitude of testosterone elevation, and results of imaging were felt to be most strongly indicative of ovarian hyperthecosis, and the patient underwent laparoscopic bilateral salpingo-oophorectomy and hysterectomy. The right ovary was 2.3 cm in largest diameter and approximately 90% replaced by an orange-red mass that showed Sertoli and Leydig cells on microscopy, immunohistochemical staining for the sex cord proteins inhibin and calretinin, and presence of the Leydig cell marker melan A. It was classified as well differentiated. Additional CT imaging and robotic assisted laparoscopy confirmed a stage IA tumor. One month after surgery, hyperandrogenemia had completely resolved (total testosterone < 10 ng/dL, androstenedione 0.379 ng/mL, and DHEAS 99 mcg/dL), and changes of virilization had mostly regressed at an eight months appointment. Discussion: SLCTs are a type of sex-cord stromal ovarian tumor. They constitute < 0.5% of ovarian tumors but account for approximately 75% of testosterone-secreting ovarian masses. This patient’s case was unusual for multiple reasons: 1. Age - most SLCTs are diagnosed in the second or third decade, 2. Imaging - CT and ultrasonography usually show a solid or solid and cystic adnexal mass, and co-existing adrenal nodules are rare, likely due to typical young age of presentation, and 3. Pattern of androgen elevation - DHEAS was more than two-fold elevated, and usually < 10% of DHEA and DHEAS are produced by the ovaries. However, DHEAS fell significantly after oophorectomy. SLCTs are a potential etiology of virilization in postmenopausal women even in the absence of a detectable adnexal mass and when biochemistries and imaging raise the possibility of an adrenal source of androgen.

Frontal fibrosing alopecia: a clinicopathological study of 22 cases from Shiraz, Southern Iran

Background: Since its recognition, frontal fibrosing alopecia (FFA) has increasingly been studied globally in terms of its diverse aspects. Having found no studies describing this condition in Southern Iran, we examined the different clinicopathological features of patients with FFA who referred to Faghihi Hospital, Southern Iran, between 2013 and 2018. Methods: We searched the archives of the Pathology Department of Faghihi Hospital for the cases with a diagnosis of FFA. Due to its similar histopathologic features with lichen planopilaris, the final diagnosis was made using clinical correlations. Results: Twenty-two patients were enrolled; all were female. Fifteen (68.2%) presented with the disease before menopause. Besides frontal and/or temporal hairline involvement in all the patients, eyebrow alopecia, eyelash loss, body hair loss, and facial papules were present in 81.8%, 27.3%, 50%, and 68.2% of them, respectively. Dermoscopic findings included follicular opening loss (100%), honeycombing of the scalp (81.8%), multiple white dots (77.3%), perifollicular erythema (63.6%), and perifollicular scales (59.1%). The histopathologic examination revealed follicular dropout (95.4%), perifollicular lymphocytic infiltration in the infundibulum and isthmus of the follicles (81.8%), perifollicular fibroplasia (77.3%), intact interfollicular epidermis (59.1%), mild perivascular lymphocytic infiltration in the upper dermis (54.5%), and apoptotic keratinocytes in the infundibulum and isthmus (50%). The most common comorbidity was hypothyroidism (40.9%). Conclusions: Thediagnosis of FFA should be considered in both premenopausal and postmenopausal women. Eyebrow alopecia, eyelash loss, body hair involvement, and facial papules are helpful clues in the diagnosis. The coexistence of hypothyroidism with FFA suggests immunological involvement in the pathogenesis.

Characterization and classification of different female hairline patterns in the Thai population.

The hairline is an essential component of the human face. Disfigurement of the hairline may cause physical and psychological problems. Standard guidelines do not exist for female hairline designs, average values of infratemporal portion, hairline classifications, and preferences. We aimed to study hairline characteristics in Thai females and further compare the values with previous studies in different populations. Furthermore, we aimed to introduce a comprehensive hairline classification system that allowed an easy and detailed phenotypic characterization of female hairline. Healthy Thai females aged over 18years were included in the study. Collection of demographic data, infratemporal measurements, and standard photography was performed. All collected data were analyzed to determine the standard values of each hairline dimension for comparison to previous studies. Two hundred and twenty-nine females, with a mean age of 32.4±8.6years, participated in this study. The mean mid-frontal line was 6.45±0.89cm, which was not correlated with age. Lateral mounds, widow's peaks, and cowlicks were observed in 42.35%, 24.45%, and 1.74% participants, respectively. Our study revealed five patterns of the frontal hairline and four patterns of the temporal hairline. The mid-frontal line in Asian females trended longer than that in Caucasians, without statistical significance. Measurements of the infratemporal portions in Thai females revealed no change with age, and the mid-frontal line showed no statistically significant differences between Korean and Turkish participants. The hairline classification system introduced in our study was comprehensive and would be easily applicable in clinical practice. Female hairline dimensions and patterns reported in our study could provide reference values for hairline design in hairline restoration surgery as well as assist in accurate diagnosis of hair disorders.

Algorithm for Temple Reconstruction With Consideration of Anatomic and Defect Characteristics.

The temple is an intriguing region of the face with unique anatomic features, such as the temporal hairline, concave contour, and close proximity to vital structures like the frontal branch of the facial nerve. However, cancerous skin lesions can plague this sun-exposed region and, when excised, it can result in large and significant defects. Reconstruction in this area is a formidable challenge for surgeons, as it requires comprehensive knowledge of temple morphology and the use of creative techniques in order to minimize disruption of surrounding functional and aesthetic structures. In this study, we describe our experience with temple reconstruction in patients of varying defect size and depth. Based on these defect characteristics, anatomic and aesthetic principles of the temple, we propose a surgical algorithm for temple reconstruction to aid surgeons in achieving optimal results.

Frontal fibrosing alopecia with involvement of the central hair part: distribution of hair loss corresponding to areas of sunscreen application

Frontal fibrosing alopecia (FFA) typically presents with band-like scarring alopecia in the frontal and temporal hairline along with eyebrow loss. Although this type of hair loss is being seen with increased frequency worldwide, the etiology of the condition is unknown. Studies have suggested a potential environmental role with moisturizers and sunscreens being possible triggers. Herein, we present a 42-year-old woman with a biopsy-proven diagnosis of frontal fibrosing alopecia. In addition to the typical pattern, she also had a striking linear patch of hair loss along her central part. This was an area where she regularly applied sunscreen for many years. Although a causative role for sunscreen ingredients in the development of FFA has not been proven, the evidence accumulated thus far, including our suggestive case, substantiates the need for further study. Additionally, increasing awareness of this potential effect leading to appropriate counseling regarding cessation of possible triggers may be critical for the prevention of further hair loss.

S13-05 SESSION 13: HYPERTELORISM / CRANIOFACIAL CLEFTS A NOVEL ORBITO ENCEPHALO CRANIAL DYSPLASIA VARIANT TESSIER 9 FACIAL CLEFT

Introduction: We present a group of patients with dysplasia involving mesencephalon, prosencephalon, calvarium, scalp, hairline and lateral orbit. These features are classifiable as a variant Tessier 9 cleft. Clinical and radiologic findings are presented, as well as outcomes of treatment. Methods: Retrospective chart review, clinical photographs, 3D CT and MRI exams. Results: 15 patients were included. 9 patients were treated for congenital hydrocephalus due to aqueductal stenosis, and 7/9 had residual craniomegaly. Radiologic findings include pontine or quadrigeminal plate “lipoma” (n=4), squamosal bone dysplasia (n=3), Supernumerary intra-parietal suture (n=7), partial or total synotosis of the coronal or lambdoid sutures (n=5). Hairline findings include a pathognomonic temporal hairline “Omega-dot” or “atoll-like” deformity (n=12), temporal hairline peak (n=2), interrupted lateral eyebrow (n=6) and absent frontal process of the zygomatic bone (n=1). Using the following diagnostic algorithm: 2 findings = possible/tentative diagnosis, 3 or more findings = positive/confirmed diagnosis, our group was divided into 13 positive and 2 possible diagnoses. Conclusion: These patients display a constellation of rare/pathognomonic clinical symptoms with associated radiologic findings and prognostic implications. Patients with congenital hydrocephalus that harbor this anomaly may retain a craniomegalic skull when treated with standard protocols. We present the diagnostic criteria used in this series. Further radiologic examination of brain anomalies and genetic sequencing are ongoing.

Lichen planopilaris in a Latin American (Chilean) population: demographics, clinical profile and treatment experience.

Lichen planopilaris (LPP) is characterized by lymphocytic infiltrate, fibrosis and potential destruction of the hair follicle. Demographic and clinical studies in LPP are limited, and racial differences have not been thoroughly investigated. To analyse epidemiological data and clinical profiles of Chilean adults with LPP, and report on the treatments used. This was a retrospective review of medical records and clinical follow-up of Chilean adults with a clinical and histopathological diagnosis of LPP. Treatment response was categorized clinically as none (with progression of condition), mild or satisfactory. The study assessed 103 patients with LPP [67 women (mean age 54.1 years) and 36 men (mean age 39.1 years)]. Of the 103 patients, 41 women and 34 men were diagnosed with classic LPP (CLPP) and 26 women and 1 man with frontal fibrosing alopecia (FFA), while Graham-Little-Piccardi-Lassueur syndrome (GLPLS) was identified in 1 man. Men with CLPP had a significantly (P < 0.001) earlier age of onset than women. Scalp dysaesthesia, erythema and peripilar hyperkeratosis were common findings, and 51 (66%) of patients with CLPP had cicatricial patches, most of which were circumscribed in the vertex area. All patients with FFA had band-like scarring in the frontal and temporal hairlines. Morbidities associated with LPP were hypothyroidism, dyslipidaemia, hypertension and depression. For most patients, treatment halted or improved their inflammatory/scarring condition. A sustained combination of at least one topical (clobetasol, minoxidil and salicylic acid) and one systemic (cetirizine, hydroxychloroquine, finasteride, methotrexate and isotretinoin) medication was necessary in all of our patients with LPP. This investigation is one of the first to describe the demographic, clinical and therapeutic features of LPP in a Latin American population. Similar profiles to previous reports may encourage research in larger multicentre international studies.

Use the technique of three layers suspension to lift the mid-low face

Objective To explore an ideal surgical method for mid-low face lifting. Methods In this procedure, the first surgical step was subcutaneous undermining that was performed through the incision along temporal hairline, anteriorear, and mastoideae. It extended distally beyond the furthest skin fold and along the mandibular border or the midline of the neck if nacessary. Then three layers suspension were performed, which included three procedures: first, SMAS was purse string sutured in certain direction; secondly, the malar fat pad was suspended to tow directions backward and upward and anchored in the periosteum of zygoma and SMAS too; lastly, through traction suture of reducing tension step-by-step, lots of the tension was relieved from the incision; at the same time, new retaining ligaments between flap and SMAS were reestablished. And redundant skin was removed in incision at the end of the procedure. Results A total of 22 cases received this operation. 16 cases were followed up from 3 months to 24 months after operation. The results of operation were divided into three degrees: excellent, acceptable and poor; and those were evaluated by patients themselves. 14 cases obtained excellent result (87.5%) , 2 cases regarded that their results were acceptable (12.5%). The total satisfactory rate was 100%. None serious complication occurred in those cases except some slight complications, such as local edema, skin numbness and small hematoma which relieved in 3 to 6 months after operation. Scar was inconspicuous. Conclusions This technique can correct the posies of lower tow-third face better, especially for mitigating the nasolabial fold and enhancing the elastic of face skin. Simultaneously, it is an effective, safe and simple technique. Key words: Face lift; Superficial musculoaponeurotic system; Malar fat pad

Defining Temporal Hairline Landmarks.

Brow dermoids are benign pediatric neoplasms. Endoscopic resection requires incisions placed within the temporal hairline, which is often difficult to reliably locate in infants. The authors studied adult and pediatric patients to define the location of the hairline in relationship to simple facial landmarks. Adult and pediatric patients who were seen in preoperative consultation for facial surgical procedures were identified and included in the study. Patients with a history of facial trauma, surgery, or congenital anomalies were excluded. Digital photographs were analyzed to measure corneal white-to-white diameter. Lines were drawn connecting the tragus to the lateral canthus and from the inferiormost aspect of the earlobe bisecting the first line (line A). The maximal distance between line A and the temporal hairline was recorded. One hundred sixteen patients met the inclusion criteria, 81 adults and 35 pediatric patients. Average age was 55.9 years in adults and 3.2 years in the pediatric group. Measurements were normalized to the corneal diameter. Average temporal hairline distance from line A was 25.0 mm in adults and 21.8 mm in the pediatric group. Hairline position was not correlated with age or sex. The temporal hairline can be reliably located relative to a line drawn from the inferior aspect of the earlobe to the midpoint of the line connecting the lateral canthus and tragus. The temporal hairline is within 30 mm of this line. When designing a temporal hairline incision in infants, it can be safely placed 30 mm or more posterior to this line to ensure a well-hidden scar.

The Diagnosis and Treatment of Hair and Scalp Diseases.

Hair loss is caused by a variety of hair growth disorders, each with its own pathogenetic mechanism. This review is based on pertinent articles retrieved by a selective search in PubMed, on the current German and European guidelines, and on the authors' clinical and scientific experience. Excessive daily hair loss (effluvium) may be physiological, as in the postpartum state, or pathological, due for example to thyroid disturbances, drug effects, iron deficiency, or syphilis. Androgenetic alopecia generally manifests itself in women as diffuse thinning of the hair over the top of the scalp, and in men as receding temporal hairlines and loss of hair in the region of the whorl on the back of the head. Alopecia areata is patchy hair loss arising over a short time and involving the scalp, eyebrows, beard, or entire body. The hair loss of alopecia areata is reversible in principle but hard to treat. Folliculitis decalvans is a form of alopecia with scarring, characterized by inflamed papules, pustules, and crusts at the edges of the lesions. Lichen planopilaris generally presents with small patches of baldness, peripilar erythema, and round areas of skin scaling. Kossard's frontal fibrosing alopecia is characterized by a receding hairline and loss of eyebrows. Hair loss is a symptom, not a diagnosis. The pathogenesis of the alopecias involves a range of genetic, endocrine, immune, and inflammatory processes, each of which calls for its own form of treatment.

A Novel Surgical Approach to Chronic Temporal Headaches.

The targets for the surgical treatment of temporal headaches are the zygomaticotemporal branch of the trigeminal nerve and the auriculotemporal nerve. The former is often accessed by means of an endoscopic brow approach or potentially by laterally extending a transpalpebral incision. An established surgical approach, the Gillies incision, was modified to access the zygomaticotemporal nerve, as it was felt to combine the advantages of the traditional techniques. Nineteen patients underwent zygomaticotemporal nerve decompression and neuroplasty or neurectomy and muscle implantation using this surgical approach. A 3.5-cm incision was made behind the anterior, temporal hairline and the zygomaticotemporal branch of the trigeminal nerve was approached directly, remaining superficial to the deep temporal fascia. Each patient was assessed preoperatively and postoperatively with regard to the frequency, duration, and severity of their symptoms to calculate a Migraine Headache Index score. All evaluations were performed at least 1 year postoperatively. The mean preoperative Migraine Headache Index score was 131.7 and the mean postoperative score was 52 (p < 0.0001). There were no surgical complications. There appeared to be no differences between those patients that had decompression and neuroplasty versus those that underwent neurectomy and implantation, as both groups experienced significant reductions in Migraine Headache Index scores following the procedure. The anterior temporal approach to the zygomaticotemporal nerve is both safe and effective. The advantages of this approach include a hidden scar, the ability to directly manipulate the nerve for transection or preservation, and access to the auriculotemporal nerve through the same incision.

A Comment on Frontal Fibrosing Alopecia (Axel Munthe's Syndrome).

Frontal fibrosing alopecia (FFA) represents a peculiar condition with a quasi-symmetrical, marginal alopecia along the frontal and temporal hairline with scarring. Steven Kossard is credited with the original description of the condition in 1994. Since its first description, FFA has become increasingly common while its etiology has remained obscure. While FFA has been related to lichen planopilaris, in fact, the pattern of clinical disease presentation might be more specific for the condition than the underlying inflammatory autoimmune reaction. It has been speculated as to whether FFA existed before Kossard's original report since artistic depictions dating from the 15th to 16th century often show a high frontotemporal hairline. Rather, these represent fashionable forms of frontal pseudo-alopecia than FFA. Nevertheless, there is compelling evidence that FFA existed well before 1994 from the Swedish Physician Axel Munthe's (1857–1948) account of the distinctive features of the condition in his book of memoirs “The Story of San Michele.” Therefore, Axel Munthe is to be acknowledged the first description of FFA in 1929.