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Archive for the ‘temporal implants’ Category

The Appearance of Temporal Implant Scars

Saturday, January 27th, 2018

 

Temporal implants offer the only assured permanent method of treatment for temporal hollows and improving the width/convexity of the upper facial third. It is a procedure performed through small vertical incisions in the temporal hairline. This provides the most direct method for placement by going underneath the deep temporalis fascia to place the implant on top of the temporalis muscle. It is then pushed up against the lateral orbital rim anteriorly and the zygomatic arch inferiorly for proper positioning.

The size of the incision needed to insert the temporal implant belies its size. The flexibility of the temporal implant, which is very soft as it is intended to replicate muscle, allows it to be inserted through very small skin incisions But despite their small size, the location in the temporal region raises the understandable question from patients as how the scar appears later.

Amongst all scalp incisions those placed in the temporal region have the greatest potential to be the most noticeable. This is well known from the classic coronal scalp incision where the temporal portion often becomes the widest part of the scalp scar. But does this apply to the small vertical incisions used for temporal implants?

The answer is no. If well made with an emphasis on preserving hair follicles, these implant incisions heal extremely well. Even in short hair they are well camouflaged. I would not be so bold, however, to suggest that in a shaved head the scars would be equally undetectable.

The key to making these incisions, like any scalp incision, is to not use electrocautery except down at the bone level. Hair follicles are extremely sensitive to thermal injury and loss of hair follicles makes for a scar that appears wider than the actual scar may be due to hair loss.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – A Superior Approach for Temporal Implants

Saturday, December 30th, 2017

 

Temporal implants offer a permanent and effective augmentation method for unaesthetic temporal hollowing. They are usually inserted from the side into a subfascial pocket through small vertical skin incisions in the temporal hairline. While this incisional approach usually heals quite well, its use in the male patient who shaves his head or has a close haircut along the sides of his head must be considered with caution.

An alternative insertion approach for temporal implants is from a superior point of access. Coming from a northern point in the scalp is also a useful approach. A superior-inferior dissection direction actually offers an easier method off implant placement, particularly for the extended temporal implant style.

The most convenient time to use a superior approach is when the scalp area is already open from another procedure. Such procedures would be brow bone reductions, brow lifts, hairlines advancements and any form of forehead bone reductions. From these approaches the temporalis fascia is seen coming right up to the bony forehead.  A horizontal incision can be made in the fascia through which a pocket can be dissected on top of the muscle down to the zygomatic arch. The width of the incisional opening allows for the implant to be placed in its correct vertical orientation.

Getting to the temporalis fascia can be done from a variety of directions. The lateral incision in the temporal hairline provides the most shortest route. The superior scalp incision pzrovides the best orientation for implant placement. The postauricular approach provides a scarless approach but the most challenging for subfascial pocket distance and for implant orientation. All incisional methods for placement of temporal implants work, and I have used them all, but the superior approach is a natural option the forehead is already open for other procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Temporal Anatomy – Implications for Injection and Temporal Implant Augmentation Methods

Thursday, August 17th, 2017

 

Temporal hollowing has become a target for aesthetic treatments with the expansion of injection therapies. Injectable fillers and fat injections are the most common temporal augmentation methods. The ease of their use as non-surgical and minimally invasive treatments makes them very appealing to patients and doctors alike. However the temporal region is one of the least satisfying facial areas for injection from an aesthetic standpoint due to unpredictable volume retentions and evenness of the result. In addition, although rare, complications such as blindness and cerebral emboli have been reported. Understanding the anatomy of the temporal would help provide safe guidelines for injectors.

In the September 2017 issue of the Aesthetic Surgery Journal, an article was published entitled ‘Anatomical Study of Temporal Fat Compartments and its Clinical Application for Temporal Fat Grafting’. In this beautifully illustrated cadaveric study, the authors dissected both sides of the temporal regions in eight cadavers looking at its neurovascular and fat compartment anatomy. Their specific intent was to understand the anatomy for the purposes of safe injectable fat grafting. In the subcutaneous layer two fat compartments were identified as a lateral temporal cheek and lateral orbital compartments. In the deeper loose areolar tissue upper and lower temporal fat compartments were found. The anterior branch of the superficial temporal artery and the frontal branch of the facial nerve are located in the superficial temporal fascia. The nerve runs parallel with the artery. The sentinel vein has a vertical orientation and runs just behind the lateral orbital rim through the superficial and deep temporal fascia to drain into the middle temporal vein deep into the muscle.

Based on these studies, the authors conclude that all four fat compartments above the deep temporal fascia are good sites for injection augmentation, particularly fat grafting. Because of the location of the upward course of the neurovascular structures, injecting at at or behind the front edge of the temporal hairline is safe. It is most safe when done in the upper half of this temporal region. Because of the location of the sentinel vein and the frontal branch of the facial nerve, the front half of the lower temporal compartment should be approached with caution or avoided completely.

While this study was done for the purposes of augmentation done above the deep temporal fascia, it validates the safety of temporal implants…the only method of assured permanent temporal augmentation that also creates a smooth out contour. Since temporal implants are placed under the deep temporal fascia, they avoid all neurovascular structures and have no risks of many of the potential injectable temporal augmentation problems. Surgical access is done behind the front edge of the temporal hairline, a safe zone substantiated by this anatomic study. Only the anterior branch of the superficial temporal artery and the auriculotemporal nerve are in this area, both structures which are easily avoided or can be transected without any adverse sequelae.

Dr. Barry Eppley

Indianapolis, Indiana

The Forehead Widening Temporal Implant

Sunday, July 23rd, 2017

 

Temporal implants have become an effective surgical option to injectable filler and fat for aesthetic temporal hollowing. Placed in a subfascial location over the temporalis muscle through an incision behind the temporal hairline, they provide permanent temporal muscle augmentation. These now standard implants have their primary effects at the lower end of the temporal zone above the zygomatic arch, the deepest part of the concavity of temporal hollowing.

But some patients may want other areas of the temporal region augmented. They may be satisfied with the lower half of the anterior temporal zone but feel the upper half near the forehead to be deficient. They may want to create forehead widening by augmenting the upper temporal zone up against the anterior temporal bony line. as the side of the forehead.

No such high forehead widening temporal implant exists in a standard performed shape. I have had them custom made for various patients based on their 3D CT scan. The implants are designed to sit up high on the most superior end of the temporal muscle, up against the fascial attachment to the anterior temporal line. It extends down to the brow at the junction of the lateral orbital rim.  They are placed through the same temporal hairline incision that standard temporal implants are placed.

The forehead widening temporal implant has a different shape than that of the standard temporal implant. It is tapered around all of its edges but has a platform or implant thickness that extends the location of the temporal line. By adding 5 to 6mms of thickness per side the forehead is widened by a centimeter or more. The patient who seeks this implant is not concerned about classic temporal hollowing, their objective is forehead widening and they are more frequently men than women who seek it.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Extended Temporal Implant

Sunday, June 11th, 2017

 

Temporal hollowing is commonly treated by injectable fillers and fat injections. While both of these injection methods have their merits, the assured permanent temporal augmentation method is with the use of an implant. Temporal implants are newer forms of facial implants that are specifically designed to replicate the soft feel of muscle rather than that of bone. It is the only facial implant that is designed to augment a soft tissue area.

Temporal hollowing is the result of fat atrophy, muscle wasting/thinning or a combination  of both. In modest to moderate amounts standard temporal implants do well in improving hollowing. They cover the lower half  of the temporal region from the zygomatic arch upward to the level of lateral brows.

In more severe forms of temporal hollowing the concavity extends up to the anterior temporal line at the side of the forehead. This encompasses the entire anterior temporal zone for which the standard implant is deficient in height. (vertical length) As a result an extended temporal implant has been designed that can augment the entire extent of temporal hollowing should it go all the way up to the forehead.

The extended temporal implant is placed through the same incision as the standard style. The length of the incision does not need to be extended to properly place it. Once the pocket is made the implant is inserted in a horizontal orientation and then turned 90 degrees for proper placement.

The extended temporal implant offers enhanced improvement for those so afflicted with more severe facial hollowing. Thin females, patients with medication-induced facial lipoatrophy, and extreme weight loss patients are the most common aesthetic indications for use of the extended temporal implant.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Extended Temporal Implant

Wednesday, April 12th, 2017

 

Temporal augmentation is most commonly done by injection techniques using synthetic fillers or fat. While offering a non-surgical approach, their results are often not permanent and the temporal contour may be uneven or asymmetric. More recently developed temporal implants offer an assured volume and a smooth temporal contour result. Placed through a small incision inside the temporal hairline, they are inserted and positioned in the subfascial plane on top of the temporalis muscle.

While the temporal area is not dimensionally complex, it does have two distinct aesthetic zones which are important to distinguish before surgery. In mild to moderate cases of temporal hollowing, the indentation is seen lower right next to the side of the lateral orbital rim and down to the zygomatic arch. This is known as a Zone 1 temporal deficiency, the most common seen, and is treated by a standard temporal implant. When the temporal hollowing is more severe the deficiency will go all the way up the temporal line at the side of the forehead. This upper aesthetic temporal area is known as Zone 2. Some patients refer to Zone 2 as the ‘side of the forehead’ although anatomically it is the upper temporal zone. Its augmentation requires an extended temporal implant that covers both Zones 1 and 2.

The extended temporal implant has a greater vertical length than the standard temporal implant. It provides augmentation from the side of the forehead down to the cheek. It is a complete temporal implant. It is still placed through a small vertical temporal hairline incision. It is also easily adjustable to reduce its vertical length, shape or thickness as needed.

It is of critical importance to preoperatively determine the patient’s temporal augmentation needs by zone to avoid having an inadequate temporal augmentation by using the wrong implant style.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Browlift Temporal Implants

Monday, December 19th, 2016

 

Temporal augmentation has become a popular facial area of augmentation due to injectable fillers and fat. While these injectable methods offer a non-surgical treatment method, their volume retention and smoothness of contour is far from assured.

Temporal implants offer a facial augmentation method that is both permanent and straightforward to place. It is an implant unlike other facial implants as it is intended to augment muscle and not bone. As a result, the implant is very soft and flexible, feeling very much of the consistency of muscle. Another key element to its success is that the implant is placed in the subfascial position and at the subcutaneous level. Sitting on top of the muscle and under the fascia avoids any visible outline of the implant which would occur with eventual soft tissue contraction around the implant had it been placed just under the skin.

temporal-implant-placement-through-browlift-incision-dr-barry-eppley-indianapolisTo place temporal implants under the temporalis fascia, the typical approach is a small vertical incision placed back in the temporal hair. This allows easy access to the deep temporalis fascia which is entered through an additional incision in it. But there are other access incisions through which these implants can be placed. One of these is a hairline incision which is commonly used in browlift surgery. Coming from above, an incision in the temporalis fascia is made superiorly through which the implant pocket is developed and the implant placed.

Temporal implants can be used in conjunction with a browlift for a more complete forehead and temporal rejuvenation. The incision for the browlift provides direct access to the subfascial temporal pocket.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Subfascial Temporal Implants

Wednesday, December 14th, 2016

 

Augmentation of the temporal region of the face has become popularized through the use of injectable synthetic fillers and fat. While such injectable treatments can be successful, they can be plagued by unpredictability of volume retention and the need for ongoing treatments.

Like it is anywhere else on the face where aesthetic bone augmentation is desired, implants offer a permanent solution to the volume retention issue as well as that of the smoothness of the augmented contours. But the temporal region is not a bony support region and has historically not been treated by implant augmentation methods.

Temporal implants are the newest type of facial implants and have been successful for several different reasons. One reason has been the low durometer of the silicone used in temporal implants. This makes them feel more like muscle than bone which is important in a soft tissue region of the temples. That physical feature also makes them able to be inserted through incisions that are smaller than the diameter measurements of the implant.

subfascial-temporal-implant-intraop-dr-barry-eppley-indianapolisBut the single greatest reason for the current success of temporal implants is that they are placed in the subfascial and not the subcutaneous location. By placing them under the tenporalis fascia and on top of the muscle, a safe and easy dissection plane is used that avoids the frontal branch of the facial nerve. The cover of the thick fascia on top of the implant obscures any outline of the implant that would occur after tissue contraction has occurred.

Temporal implants are unique amongst facial implants since this is not a bone augmentation site. This is a muscle augmentation site since muscle is what principally comprises the temporal fossa. The feel of the implant and its location should reflect what it is intended to augment.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Temporal Implants

Sunday, November 20th, 2016

 

Background: Contour deformities in the temporal region can be caused by either bone or muscle deficiencies. They often develop from prior surgeries such as craniotomies for tumors and infantile cranial vault surgeries for craniosynostoses. Elevating the temporalis  muscle at any age often results in muscle retraction and/or muscle atrophy. Even though the surgeon may resuspend the temporalis muscle at the end of the operation some degree of temporal contour deformity often still occurs.

Recontouring of many temporal deficiencies can be done by either fat injections or implants. Fat injections have their merit but they can be unpredictable in terms of both survival and contour shape. Implants of various materials have been used for decades for many forms of skull contouring. While many cranioplasty materials have been used in the temporal region, they have less than ideal properties because they are intended for bone contouring not that of muscle augmentation.

The temporal region is comprised of a thick layer of muscle in its anterior region beside the eye. When the muscle retracts or atrophies a pronounced indentation will occur. Filling in the indentation with a satisfactory aesthetic result can be difficult as this is a soft skull area and not a hard one.

medpor-temporal-implants-dr-barry-eppley-indianapolisCase Study: This 36 year-old male wanted to improve the appearance and feel of his tenporal regions. He had a history of a congenital skull deformity which underwent early surgery as an infant. As an adult the resultant temporal hollowing was treated by unknown temporal implants which he did not like because they were very hard and had visible irregularities and edges. A 3D CT scan showed multiple regular circular indentations in the upper temporal region which was consistent with Medpor style temporal implants.

custom-temporal-implants-design-dr-barry-eppley-indianapolisNew custom temporal implants were designed from the 3D CT scan by initially adding on the missing bone since the the scan cut off the upper temporal bone.

medpor-temporal-implant-removal-dr-barry-eppley-indianapoliscustom-temporal-implamnt-replacement-dr-barry-eppley-indianapolisUnder general anesthesia the temporal region was approached using his existing incisions from prior surgeries. The existing Medpor implants were removed in their entirety. Their underside revealed the multiple pegs of material for which they are recognized. The new custom temporal implants were put in as replacements with some trimming of its bottom thicker edge. Multiple 3mm perfusion holes were placed through the implants prior to their placement.

Highlights:

1) Temporal augmentation can be done using either standard or custom temporal implants.

2) Medpor temporal implants can be hard to shape and avoid palpable or visible edges.

3) Custom temporal implants are made from a 3D CT scan whose design can be based on how to improve the failures of indwelling temporal implant materials.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Hairline Approach to Temporal Implants

Thursday, September 8th, 2016

 

Temporal implants offer the only method of permanent temporal augmentation…that is also easily reversible. Placed in the subfascial plane on top of the anterior temporalis muscle, there is no risk of facial nerve injury nor visible edges of the implant.The skin incision to place them is done back behind the temporal hairline so it is easily hidden in the hair. This also provides an easy point of access to the subfascial plane.

But one can also place temporal implants through a hairline incision as well. I recently had a patient who came in for a variety of facial procedures including temporal implants. She happened to have had a facelift by another surgeon where a hairline incision was carried away from the ear up along the front edge of the temporal hairline. Thus an existing temporal hairline scar was present.

hairline-approach-to-temporal-implants-intraop-1-dr-barry-eppley-indianapolisHer temporal implants were placed through the anterior hairline scar. A 3.5 cm length of the scar was opened and the deep temporalis fascia exposed. The fascia was opened and a subfascial pocket developed to the lateral orbital rim anteriorly, the zygomatic arch inferiorly and just below the anterior temporal line superiorly.

hairline-approach-to-temporal-implants-intraop-2-dr-barry-eppley-indianapolisBecause she wanted a more complete temporal augmentation, a standard temporal implant was turned into a vertical orientation. The implant was slipped into the pocket with the back edge of the implant easily seen given the anterior incisional access used.

hairline-approach-to-temporal-implants-intraop-3-dr-barry-eppley-indianapolisThe fascia, dermis and skin were then closed with dissolveable sutures. This leaves her with the same hairline temporal scar that she already had.

While the hairline or pretrichial approach to temporal implants does place the fine line scar in a more visible location, it does have several advantages. It offers easier access to the subfascial pocket and allows visible assessment of the implant placement. Because there is less tissue disruption than when the incision is placed further back in the temporal hair, the procedure is also less ‘traumatic’.

For the properly selected patient, the hairline approach to temporal implant placement could be a preferred technique.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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