Forehead, temple and hairline — The upper third begins at the bone
The three determinants of the upper third and what corrects each, classification of the supraorbital ridge according to the frontal sinus, cranioplasty with its mandatory preoperative measurement, hairline management and temporal hollowing.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- The upper third is defined by three independent things: bone contour, brow position and hairline height. Confusing them is the usual reason a brow lift fails to change the face.
- The projection of the supraorbital ridge is the perceptually heaviest feature of the upper third, and it is bone: it is not corrected with soft tissue or filler.
- Before touching the ridge you must know what lies behind it: the thickness of the anterior wall of the frontal sinus decides whether burring suffices or the wall must be removed, reshaped and replaced.
- The approach is not neutral for the hairline: one moves it back, another moves it forward. In an already high forehead that difference matters more than the brow elevation itself.
- Temporal hollowing ages a face more than forehead lines and is almost never examined. Look for it in profile and against the light, not from the front.
Three determinants examined separately
When someone says their forehead bothers them, they almost never mean the skin. What they perceive is the sum of three variables worth separating at examination because each is corrected in a different plane. The first is bone contour: the projection of the supraorbital ridge and glabella, the inclination of the forehead in profile and the width of bone between the temporal lines. The second is brow position and shape, a matter of soft tissue and of the mechanics between elevator and depressor muscles. The third is hairline height, which sets how much forehead is on show. One patient may have all three altered or only one, and the costliest error is treating the second when the problem was the first: raising a brow over a heavily projecting ridge does not change the impression, it only opens the eye.
What corrects what
| Finding | Plane of the problem | The manoeuvre that solves it |
|---|---|---|
| Prominent supraorbital ridge with a shadowed gaze | Bone | Burring if the sinus wall is thick; cranioplasty with removal and replacement of the anterior wall if it is thin or the sinus is pneumatised |
| Backward-sloping forehead in profile | Bone | Augmentation with bone filler above the ridge, not burring: the problem is deficit, not excess |
| Ptotic brow tail with the body in position | Soft tissue | Selective resuspension of the lateral third. It is the commonest ptosis pattern and does not require touching the centre |
| High brow with a short forehead | Mechanical | A relative contraindication to any elevation: here lifting makes it worse. What is usually indicated is treating the depressors or lowering the hairline |
| High forehead with a receded hairline | Scalp length | Pretrichial approach with advancement, which shortens the forehead rather than lengthening it. The classic coronal does the opposite |
| Temporal hollowing with a visible bony rim | Soft tissue volume | Filling the compartment, with fat or resorbable material. It is not a skin problem and does not improve with traction |
The supraorbital ridge and what lies behind it
The projection of the ridge and glabella is the bony feature that weighs most in the perception of the upper third, which is why correcting it produces a change out of proportion to how little the scar shows. But the ridge is not solid bone: beneath it lies the anterior wall of the frontal sinus, and what can be done depends entirely on its thickness. The classic approach distinguishes three situations. Where the anterior wall is thick and the sinus small or absent, burring the bone to the desired contour suffices, the simplest and safest option. Where projection is lacking above the ridge, the manoeuvre is additive rather than subtractive: the frontal surface is augmented to soften the step. And where the anterior wall is thin or the sinus heavily pneumatised, burring to the desired contour would perforate it: the anterior wall must be removed as a fragment, reshaped outside and replaced in its new position, fixed with osteosynthesis.
The measurement you cannot skip
Which technique applies is decided not in theatre but on the CT, in sagittal section: measure the thickness of the anterior wall of the frontal sinus and the depth of the sinus itself, and compare them with the reduction the desired contour demands. Estimating by eye leads to two bad scenarios: falling short out of caution and changing nothing, or entering the sinus uncontrolled. Perforation itself is not a catastrophe if recognised and managed, but it changes the operation: it obliges assessment of the mucosa and the nasofrontal duct, and an obstructed duct with retained mucosa is what produces a mucocele years later. The prudent course is simple to state: if the planned reduction approaches the measured thickness, plan the cranioplasty from the outset and not as a rescue.
Frontal cranioplasty, step by step
- ExposureA coronal or pretrichial approach depending on what is decided for the hairline, with subperiosteal dissection over the forehead and a change to the plane deep to the temporal fascia on reaching the temporal line
- The nervesIdentify and release the supraorbital and supratrochlear bundles. Where the supraorbital nerve exits through a closed foramen rather than a notch, osteotomise its lower rim to release it without traction
- OsteotomyWith a fine saw or piezoelectric device, marking the perimeter of the anterior sinus wall and removing it as a single fragment. The piezo protects the underlying mucosa, which is its advantage here
- ReshapeOff the field, thinning and curving the fragment to the desired contour. Check that the nasofrontal duct is patent before replacing it
- FixOsteosynthesis in the new position, with the least material possible and placed where it will not be palpable. The osteotomy edges are camouflaged with bone filler
- And laterallyThe temporal line and lateral orbital rim almost always need burring too: reducing only the centre leaves an angular contour that betrays the surgery more than the original ridge did
The hairline decides the approach
It is the variable most often forgotten in planning and the one that most conditions the choice of route. A classic coronal approach, with the incision behind the hairline, lengthens the forehead as the flap is advanced backwards: in an already high forehead this is exactly what one does not want. A pretrichial approach, with the incision at the hairline itself, allows the opposite: resecting the excess in front of the hair shortens the forehead and the hairline advances. The scar hides well if the edges are bevelled so that hair grows through it, and improves further when combined with follicular grafting behind it. With either, expect scalp hypoaesthesia behind the incision, which is constant at first and usually recovers over months. The endoscopic approach is the third option: it does not touch the hairline beyond the port incisions and causes less sensory morbidity, but the bone work it permits is limited, so the choice depends on whether the problem is bone or soft tissue.
The temple, which almost nobody examines
Temporal hollowing is one of the most ageing changes and at the same time one of the least often mentioned, because patients perceive it as tiredness rather than a localisable defect. Look for it in profile and against the light, not from the front: if the lateral orbital rim and temporal line appear as visible edges beneath the skin, volume has been lost. Its origin is twofold: atrophy of the superficial temporal fat pad and, in some cases, of the muscle belly itself. The practical consequence is that it is not a skin problem and no traction improves it: a temporal lift over an empty temple stretches skin across a hollow and sometimes makes it more obvious. Treatment is volumetric — autologous fat in deep planes, or resorbable material — and is best done before or alongside any resuspension, not after. One technical detail that avoids trouble: temple infiltration is performed deep to the superficial temporal fascia, where no vessels of relevant calibre run in the usual course, and never superficially or under pressure.
Details that change the result
- The glabella and interbrow are treated together with the ridge: leaving the depressors intact over an already reduced ridge brings the frown back and with it part of the original impression.
- When burring, work with constant irrigation: the frontal bone is thin in its upper portion and burr heat produces necrosis that later shows as irregularity.
- The result is checked by palpating with the skin redraped, not by looking at bare bone: exposed bone always looks smooth, and irregularities appear when the skin returns to place.
- Scalp hypoaesthesia must be anticipated in the consent: it is constant at first with open approaches and, though it usually recovers, it takes months and disconcerts patients who were not warned.
What to do with this upper third
Does the profile show a prominent supraorbital ridge shadowing the gaze?
Is the forehead high with a receded hairline?
Are the lateral orbital rim and temporal line visible beneath the skin?
References
- 1.Ousterhout DK. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg. 1987;79(5):701-711.
- 2.Spiegel JH. Facial determinants of female gender and feminizing forehead cranioplasty. Laryngoscope. 2011;121(2):250-261.
- 3.Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg. 1999;103(1):224-236.
- 4.Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996;97(7):1321-1333.
- 5.Ramirez OM. Endoscopic subperiosteal browlift and facelift. Clin Plast Surg. 1995;22(4):639-660.
- 6.Lee A, Piraquive J, Spiegel JH. Frontal bone cranioplasty for facial feminization in gender-affirming surgery. Facial Plast Surg Aesthet Med. 2022;24(S2):S33-S37.
Related specialty: Facial Lifting & Rejuvenation