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Archive for the ‘temporal implants’ Category

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

Extended Temporal Implants

Wednesday, May 4th, 2016

 

Temporal implants are becoming a permanent treatment option for temporal hollowing. They offer a simple surgical solution using ultra soft solid silicone implants placed in the subfascial location through a small incision behind the temporal hairline. They have proven to be more than capable of creating an adequate temporal augmentation effect, equating to over 2mls of injectable filler (by the water displacement test) for a small standard sized temporal implant.

But as the experience with temporal implants increases, it has become apparent that some patients have temporal hollowing concerns that extend all the way superiorly to the forehead. Thus temporal hollowing concerns can be limited to the area to the side of the eye or extend all the way up to the anterior temporal line. (which some call the side of the forehead) The first generation standard temporal implant only creates its augmentation effect to the temporal concavity at the side of the eye.

Extended Anterior Temporal Impalnt design side view Dr Barry Eppley InsianapolisExtended Anterior Temporal Implants technique 1 Dr Barry Eppley IndianapolisA newer second generation style of temporal implant has been developed that augments the entire temporal region. It is vertically longer so that its superior edge sits right under the temporal line of the side of the forehead in its subfascial location. It is inserted with the same surgical technique as the standard temporal implant but with a few minor modifications of the basic technique.

Extended Anterior Temporal Implants technique 3 Dr Barry Eppley IndianapolisExtended Anterior Temporal Implants technique 4 Dr Barry Eppley IndianapolisThe temporal hairline incision will be about an additional .5 cm longer. (3 to 3.5 cms) The dissection heads down to the deep temporalis fascia through a branch of the superficial temporal artery will almost always be encountered. The deep temporalis fascia is incised at a length that is much greater than the length of the skin incision. The subfascial pocket is elevated widely all the way up to the bony temporal line.

Extended Anterior Temporal Implants technique 5 Dr Barry Eppley IndianapolisExtended Anterior Temporal Implants technique 6 Dr Barry Eppley IndianapolisThe extended temporal implant is introduced in the subfascial pocket horizontally and then changed to a vertical position once inside. The upper and lower ends of the implant are checked for position and the incision closed in layers including the deep temporalis fascia.

The extended temporal implant offers a broader anterior temporal augmentation effect for those patients with larger or more extensive temporal concavities. Despite its bigger size, it can still be placed through a small incision in the temporal hairline.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Head Widening Implants

Monday, February 15th, 2016

 

The width of the side of the head  is controlled by the shape of the temporal bone and the thickness of the temporalis muscle, all located above the ear. While many think the bone is the main contributing factor, the thickness of the temporalis muscle should not be underestimated. By CT scan measurements it can be seen that the temporalis muscle usually makes a bigger contribution than that of the bone to the width of the side of the heasd.

Regardless of the anatomic makeup of the width of the head, widening the narrow head must be done by either onlay augmentation of the bone (submuscular) or onlay augmentation of the muscle. (subfascial) Which implant location is best depends on whether the augmentation involve just the posterior temporal region (above the ears) or also the anterior temporal region as well. (by the side of the eye)

Head Widening Implants (anterior and posterior temporal implants Dr Barry Eppley IndianapolisHead Widening Implants (incision and subfascial dissection) Dr Barry Eppley IndianapolisMost head widening implants augmentation include both the anterior and posterior temporal regions. This can be accessed through a single 4cm incision placed in an intermediate location in the temporal hairline. Using a subfascial incision and pocket dissection, extended anterior and larger posterior temporal implants can be placed through the same point of temporal incisional access.

Head Widening Implants (implant placement and subafscial closure) Dr Barry Eppley IndianapolisHead Widening Implants (incision closure) Dr Barry Eppley IndianapolisAfter the placement of both anterior and posterior temporal implants in the subfascial pockets, the fascia os closed over the them. The skin closure is done in a two layer fashion with resorbable sutures.

Head widening or complete temporal augmentation can be done through a single small temporal incision. Two implants are needed to increase the volume of both the anterior and posterior temporal regions.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Extended Temporal Implants

Sunday, February 14th, 2016

 

Temporal implants have become the surgical approach to the treatment of temporal hollowing.  They offer a rapidly performed permanent solution that eclipses the temporary and inconsistent effects of synthetic fillers and fat injections. These implants are placed in the subfascial location on top of the temporalis muscle through a small vertical or obliquely oriented incision back in the temporal hairline.

As the use of temporal implants has increased, new styles have emerged. The initial temporal implant design was designed to treat the deepest part of the temporal hollows by the side of the eye. These implants only went up about as high as the lateral brow bone.

Extended Anterior Temporal Implant Dr Barry Eppley IndianapolisBut as more experience with temporal implants has evolved, it become clear that the extent of bothersome temporal hollowing can extend all the way up to the side of the forehead. (anterior temporal line) This has led to an extended style of temporal implants that provides some augmentation much higher than the standard style. (up to 6.5 cm vertical height from the zygomatic arch)

Temporal Implants Incision and Insertion Dr Barry Eppley IndianapolisWith such a larger temporal implant, the concern would be that a much larger incision would be needed for its placement. To avoid more than a 3 cm to 3.5 cm incision, the key is to make the subfascial pocket through a small incision. This is easy to do with instruments in a blind fashion. Then the implant can be inserted lengthwise in a rolled fashion. Once making its way through the small incision, the implant is unfurled and rotated into the proper position.

Larger styles of temporal implants can still be inserted through relatively small temporal hairline incisions. This makes the appeal of temporal implants for larger areas of temporal hollowing equally appealing as smaller amounts of temporal hollowing.

Dr. Barry Eppley

Indianapolis, Indiana

The Extended Anterior Temporal Implant

Monday, September 21st, 2015

 

Temporal hollowing is often perceived as as sign of aging but also can occur due to genetics, disease or surgery. While the aesthetic interpretation of concave temporal areas is a personal one, many people prefer a more full temporal region. This could be making the temples less hollow or all the way to a convex contour based on the shape and proportions of the face below it.

While injectable fillers and fat injections are common non-surgical or minimally invasive temporal augmentation techniques, their permanency is not assured and often require multiple treatments for the effect to be maintained. A recently introduced silicone temporal implant offers a permanent temporal augmentation effect. Placed through a small vertical hairline incision and placed under the fascia, the temporal implant corrects temporal hollowing  by adding volume to the muscle. This is unlike every other facial implant whose objective is to augment the underlying bone.

While standard temporal implants can very effectively improve temporal hollowing, their effects are relegated to the lower anterior temporal region by the side of the eye. This is where the deepest part of temporal hollowing occurs due to the shape of the temporal bone way below the skin surface. But the negative aesthetic effects of temporal hollowing can extend all the way up to the side of the forehead (anterior temporal line) which is beyond the augmentative effects of the standard temporal implant design.

Extended Anterior Temporal Impalnt design side view Dr Barry Eppley InsianapolisExtended Anterior Temporal Implant Design front view Dr Barry EppleyFor augmentation of the total anterior temporal region, a different temporal implant design is needed. The extended anterior temporal implant offers a design that extends from the zygomatic arch to the anterior temporal line vertically. It is thicker inferiorly and tapes into a fine edge at its superior extent. While every patient is different in size this new temporal implant is adequate for most patients with a lower thickness of 6mms.

Extended Anterior Temporal Implant placement surgical technique 1 Dr Barry Eppley IndianapolisExtended Anterioe Temporal Implant placement technique 3 Dr Barry Eppley IndianapolisThe extended temporal implant is placed identically to that of the standard design. A small 4 cm vertical incision is made way back in the temporal hairline. This is usually above and behind the bifurcation of the temporal artery. The deep temporal fascia is found, incised and the implant pocket made bluntly and blindly. The pocket is developed  based on preoperative markings of the desired areas of anterior temporal augmentation. The implant is inserted and placed beneath the deep temporal fascia and on top of the temporalis muscle.

By providing  augmentation of the temporal region between the side of the forehead and the zygomatic arches, a more complete temporal augmentation is achieved. The larger extended anterior temporal implant is just as easy to place as the standard temporal implant. Clearly identifying the extent of temporal augmentation effect that a patient wants will allow one to choose the better implant design. It is often assumed by patients that the standard temporal implant provides an augmentation of the whole anterior temporal zone.

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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