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Archive for the ‘temporal implants’ Category

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

Temporal Implants vs Injectable Filler Volume Effects

Saturday, July 2nd, 2016

 

Temporal augmentation has become a more recent aesthetic procedure. It is most commonly done using a wide variety of synthetic injectable fillers as a non-surgical approach or fat injections for more of a surgical procedure. While successful at creating a temporal augmentation effect, the cost and lack of persistence of injectable fillers and the unpredictability of fat injections leaves room for a more predictable and permanent treatment option.

The development of temporal implants provides another option for temporal augmentation. Now available in a variety of shapes and sizes, the lower half of the non-hair bearing temples or the entire temporal region up to the forehead can be augmented. Placed through a small vertical incision in the temporal hairline, they are placed in a subfascial location as a muscle-enhancing implant. But it is an invasive procedure and requiring the need to have a synthetic implant placed so some patients  may want to have an injectable treatment method first.

A relevant question in this spectrum of temporal augmentation methods is how does an injectable filler in the temples compare to a temporal implant? How does the volume of an injectable filler compared to the displacement effect caused by a solid implant?

Temporal Implant Volumes Dr Barry Eppley IndianapolisComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would be equal to the volume of the implant. Using the newer temporal implants of its two available sizes, their weights in grams and volume displacement were as follows:

TEMPORAL IMPLANTS

Small               3.95 grams    1.4 ml

Medium          7.17 grams     2.1 ml

Large             12.26 grams    3.2 ml

Temporal Implants vs Injectable Fillers Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to temporal implants can be directly done. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to almost half of a small temporal implant. Larger temporal implants more directly compare to close to two 1.5cc syringe of Radiesse.

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – The Versatile Temporal Implant

Sunday, May 8th, 2016

 

Augmentation of temporal hollowing has become a popular aesthetic procedure. While synthetic fillers and fat offer simplicity, they do not create a permanent treatment solution. Temporal implants fill that need and can be placed through a relatively minor surgical procedure.

Temporal Implant Design Dr Barry Eppley IndianapolisThe first generation standard temporal implants are of a soft flexible silicone material that is designed to simulate muscle tissue. It has a shape that simulates the lateral orbital rim anteriorly, the zygomatic arch inferiorly and then tapes superiorly and laterally into a tapered edge. It is longer horizontally than vertically and is designed to treat the deepest part of temporal hollowing which is at the lower half of the anterior temporal region between the eye and the temporal hairline.

Temporal Implants modifed use Dr Barry Eppley IndianapolisBut some patients have temporal hollowing that extends up higher and desire a temporal augmentation effect that is vertically longer. In these cases the standard temporal implant can be rotated 90 degrees so that it is placed with the longer horizontal part vertically and the vertical part horizontal. It is also important that the right and left temporal implants be switched when making this implant re-orientation. In other words, a right temporal implant is used on the patient’s left side that is rotated 90 degrees in orientation n the left temporal hollow.

The standard temporal implant offers some versatility in how it can be used to create its temporal augmentation effect. In the subfascial location, it offers two options for the extent of its effect based on how the implant is oriented.

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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