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Archive for the ‘temporal reduction’ Category

Case Study – Posterior Temporal Reduction for the Wide Head

Sunday, November 19th, 2017


Background:  The side of the head is an often overlooked aesthetic area whose shape can really only be appreciated in the frontal view. While great attention is paid to the anterior temporal region by the side of the eye due to its facial proximity, the more obscure posterior region is seen back in the hair-bearing temporal region above the ear. It doesn’t have much topographic variation other than an overall linear or more rounded shape. With hair it is hardly noticeable at all.

But in the man whose has very closely cropped hair or shaves his head, all areas of the head become more aesthetically important. The shape of the side of the head achieves an awareness not previously seen. While there are no established aesthetic standards for which its shape should be, an excessive amount of convexity to it s usually deemed unaesthetic.

In determining how to reduce excessive fullness on the side of the head the pertinent question is what makes it so. While often believed to be a bone problem, and the bone does make some contribution to it, it is equally if not more than made up of the temporals muscle. The thickness of the posterior temporals muscle can be surprisingly thick particularly around the top of the ear.

Case Study: This young male was bothered by the convexity on the sides of his head above his ears. While he felt this head overall was too big he was most bothered by the fullness on its sides.

Under general anesthesia the resection of the posterior temporals muscle was approached through a small vertical incision just above his ears. The entire posterior muscle mass was removed behind a vertical line going up from the ear but leaving the overlying fascia intact.

When seen years later, the healing of the scalp scar was remarkably faint. The reduction in the fullness of the sides of the head was apparent and had changed from a bowed out shape to a straight line.

Temporal reduction is an effective procedure for reducing the fullness on the sides of the head. It is a myectomy-based procedure that does not incorporate any bone reduction achieve its effects. It causes no jaw movement or chewing dysfunction. The procedure has evolved today to one that places the incision behind the ear in the postauricular sulcus so it is essentially ‘scar-free’.


1) A wide side of the head is caused partially by the thickness of the posterior belly of the temporals muscle.

2) Resection of the posterior temporal muscle is an effective technique for reducing the convexity on the side of the head.

3) Removal of part of the temporal muscle does not cause any long-term jaw movement restrictions.

Dr. Barry Eppley

Indianapolis, Indiana

Five Concepts about Temporal Reduction (Wide Head Narrowing Surgery)

Monday, October 9th, 2017


Reduction of the wide head is a procedure primarily performed by removal of the posterior temporal muscle. (temporal reduction) Besides the fact that few patients and surgeons even know such an aesthetic operation can be performed or exists, it is common that those who discover it grapple with why it works or have concerns about potential adverse functional facial effects. From that perspective let me address five concepts about temporal reduction surgery.

The Width of the Posterior Temporal Muscle Is Bigger Than One Thinks. The thickness of the side of the head above the ears is composed of three main tissues; skin, muscle and bone. While the temporal bone does make a major influence on side of head convexity, the posterior temporal muscle can often make up 40% to 50% of its thickness as well. In many male patients I have seen the muscle be 7mm to 9mm in thickness per side.

A Vertical Line from the Top of the Ear is the Excision Boundary. The anterior extent of the posterior muscle removal is determined by this line. Albeit somewhat arbitrary as there is more real defined transition between its anterior and posterior bellies, it is were the muscle starts to become much thicker. It is also a convenient point of access from the postauricular sulcus incision placed behind the ear.

Removal of the Posterior Temporal Muscle Causes No Jaw Dysfunction. Seemingly defying the purpose of its very existence, no long or even short-term jaw dysfunction has ever been encountered. If the patient opens their mouth really wide in the first day or two they may feel so tightenness/discomfort but this quickly passes. Undoubtably this occurs because the much larger anterior muscle belly remains (it makes up 70% of the overall temporal muscle mass) and the posterior belly makes an adjunctive but not essential contribution to jaw movements.

The Overlying Fascia of the Posterior Temporal Muscle is Preserved. Keeping the tight overlying fascia allows it to have a contouring effect. Initially the cut edge of the muscle will have a palpable step-off. The overlying fascia has a dampening effect on the remaining muscle edge and acts as a barrier to prevent skin adhesion directly to the now exposed bone. Its preservation also maintains the overlying vascular pedicle of the posterior branch of the superficial temporal artery.

Posterior Temporal Muscle Removal Takes Six Weeks To See Its Final Result. The dressing applied right after surgery is removed the following day. At its removal the flattening result is immediately apparent and usually satisfying. But then the swelling sets ion and it will be another 6 to 8 weeks before the initial result seen recurs.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – The Fate of the Cut Muscle Edge in Temporal Reduction

Sunday, August 6th, 2017


Temporal reduction is an effective method for narrowing the wide head. The wide head is defined as the area above the ears that has too much convexity or fullness. Extreme fullness at the sides of the head occurs when the width of the head gets near a vertical line drawn up superiorly from the inside of the superior helix of the ear. But many affected patients may feel they have too much convexity even when its width is well inside the profile of the ear.

While many feel that temporal bone reduction is the key to head width reduction, it actually is not. The thickness of the posterior temporal muscle is what constitutes a significant part of the side of the head. Its removal makes an immediate and visible reduction in its convexity, changing it to a completely or near complete flat profile. Surprisingly the removal of the posterior temporal muscle has no functional impairment on lower jaw motion or function.

In the technique of temporal reduction by myectomy, which is usually performed through a postauricular incision, a vertical cut through the temporal muscle is made from the attachment of the ear superiorly to the temporal line at the top of the skull. All muscle behind this line is removed leaving the overlying fascia in place. With muscle thicknesses averaging 7 to 9mms in thickness this leaves a very palpable and sometimes visible step-off in the temporal contour. The posterior cut edge of the large remaining anterior temporal muscle is cauterized for both hemostasis and in the belief that muscle atrophy will eventually smoothest the shape of the cut edge of the muscle.

I had the opportunity to validate what happens to the back edge of the cut temporalis muscle. Three years previously as part of awn overall skull reshaping procedure, the posterior temporal muscle was resected in a full-thickness vertical fashion from the bony temporal line inferiorly down to the ear. In a more recent skull reshaping procedure on the same patient, the temporal regions were inspected. It was observed that the original cut edge of the muscle does thin out and recontour with healing as suspected.


Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Head Narrowing by Posterior Temporal Muscle Reduction

Sunday, July 9th, 2017


Background: The shape of the head is influenced by five different surfaces. These consist of the front, back, sides (2) and the top. Each surface has an effect on the appearance of the overall head shape. While there is specific numerical numbers that define the ideal head shape, there are certain convexities and shapes to it that make it either appealing or unaesthetic.

The shape of the side of the head is rarely thought unless it has some abnormal shape to it. The side of the head, also known as the posterior temporal region, can be seen as unaesthetic if it is too wide (increased convexity) or is too narrow. (no convexity) By far the more common concern is one of too much convexity which creates the ‘lightbulb’ appearance. This is where it is wide high above the ear and then becomes more narrow as it gets closer to the ear.

The posterior temporal region is composed of five layers. These consists of the skin, subcutaneous fat, fascia, temporal muscle and bone. While all layers make a contribution to its thickness, the muscle represents a more significant component than most think.

Case Study: This 36 year-old male was bothered by the very wide sides of his head. He had short hair and his head width was visibly disproportionate to the rest off his head and face. A posterior temporal muscle resection was planned to narrow the sides of his head whose outline was drawn on before surgery. He did not find a low temporal incision unacceptable so the incision was made beyond the sulcus of the back of the ear. (in most cases of posterior temporal reduction the incision is kept completely behind the ear)

Under general anesthesia the entire posterior temporal muscle was removed in a subfascial manner for a head narrowing effect. The anterior border of the resection was made along an oblique line from the top of the ear superiorly up to the anterior temporal line. The size of the muscle was exceptionally thick.

The narrowing effect of the muscle removal was immediately evident as would be expected with a muscle thickness of 7mm to 9mms.

Head narrowing is done by muscle removal and not bone removal. There are no functional deficits created by removal of the entire posterior temporal muscle. (limitation of jaw motion or even creation of jaw stiffness)


  1. The posterior temporal muscle makes up a significant thickness of the side of the head.
  2. An overly convex side of the head can be reduced by posterior temporal muscle excision.
  3. Side of the head reduction (head narrowing) can be done in most cases by a hidden incision behind the ear.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Temporal Reduction for Head Width Narrowing

Saturday, June 3rd, 2017


The size of one’s head can be judged from different dimensions. One of these dimensions is head width, which is judged by the appearance or size of the head above the ears. A normal head width does not stand out and has either a flat to a very slightly convex shape. It lies well inside a vertical line drawn up from the superior arch of the ear. A narrow head width has a straight line or concave appearance between the superior temporal line and the ears.

Conversely, a wide head has a distinct convex shape that bows outward above the ears. Its width may equal the protrusion of the ear. In very large head widths the tissues may even make the top of the ear sticks out at its helical root attachment.

The side of the head is anatomically composed of bone, temporalis muscle and skin. It is structurally simple and there are no vital blood vessels or nerves in the area. What is often not appreciated is how much the temporalis muscle thickness contributes to the width of the head. Even though the posterior temporal muscle belly is far thinner than its anterior portion, it still has a thickness of 5 to 7mms. (if not more in most men)

Understanding the thickness of the posterior temporalis muscle serves as the basis of the temporal reduction procedure. Removing the entire thickness of the muscle can result in a very visible and distinct narrowing of the side of the head. In so doing there are no functional implications of jaw motion due to the remaining larger anterior muscle belly.

The key in doing posterior temporal reduction is the incisional access. A long vertical incision on the side of the head is not aesthetically acceptable for most patients. A more limited incision for its removal must be used. This can be either a completely postauricular incision or a combination of an upper postauricular incision with a small vertical extension above the ear. The muscle is released in a subfascial manner and then delivered through the much smaller incision.


Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transcoronal Temporal Reduction

Friday, March 24th, 2017


Background: The width of the head is controlled by the thickness of tissues above the ears. This consists of skin, fat, muscle and bone. Of these four tissue elements, it is surprising for most people to know that the muscle layer is the thickest of all of them. The posterior belly of the temporal muscle is a lot thicker than is usually appreciated often being 7mm to 9mms in thickness.

The temporal or head width reduction procedure that I have developed uses the removal of full thickness muscle to achieve its effect. While most patients and surgeons want to grind down the bone, it is this soft tissue reduction that has the greatest effect. Removing this portion of the temporalis muscle sees like it would create functional problems with lower jaw opening, but it does not. This is because the bulk of the temporalis muscle is located in the anterior belly and there are other muscle (pterygoid and masseter muscles) that play a role in jaw motion as well.

Temporal reduction is usually done through limited incisions that are hidden as much as possible. This is because most patients that have heads that are perceived as being too wide or convex are men who have close cropped hairstyles or shave their heads. Small temporal or postauricular incisions are usually used. In rare cases where a coronal scalp scar already exists or other procedures are being done that necessitate such a long scalp incision will it be done with such open exposure.

Case Study: This young middle-aged male had a prior history of brow bone reduction and an existing full length coronal scalp scar. He was bothered by the width at the sides of his head and its protruding convex shape.

Posterior Temporal Muscle Resection and Parietal Skull reduction intraop bnefore and after Dr Barry Eppley IndianapolisBecause he already had a full coronal scalp incision, a full open approach was done for wide open access to the posteror temporal areas above his ears. The full thickness of the muscle and the overlying fascia were removed.

Temporal Muscle Reduction result front view Dr Barry Eppley IndianapolisHis after surgery results show a reduction in the width of the sides of his head with less convexity. He had no jaw motion restriction or pain even right after the surgery.


  1. A wide side of the head can be reduced by temporal muscle reduction.
  2. The most significant temporal reduction of muscle can be done through an open scalp incision
  3.  Complete temporal muscle removal usually results in significant head width narrowing.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Head Width Reduction by Muscle Removal

Tuesday, November 29th, 2016


Background: An aesthetically displeasing size of the head can occur at various skull areas. One such area is at the side of the head most commonly located above the ears. When it is too wide there is a noticeable convexity or bowing out of the temporal region above the ears. A more aesthetically pleasing shape at the side of the head is more of a straight line or one with a minimal convex shape to it.

Because the temporal region is located on the side of the skull it is logical to assume that it is bone and can only narrowed by bone reduction. But careful analysis of many CT scans reveals the thickness of the posterior temporal region above the ears is about 50:50 bone and muscle. The thickness of the posterior temporal muscle is a lot thicker than most would think. In men it is 7 to 9mm thick while in women it can be 5mm to 7mms thick.

Thus removal of the posterior temporalis muscle offers an effective treatment strategy for narrowing the side of the head. It can also be done with less scar that would be required for temporal bone reduction.

posterior-temporla-muscle-thicknessCase Study: This 36 year-old male wanted to reduce the fullness on the sides of his head. A CT scan revealed that the side of the head above the ears had a sufficiently thick muscle layer that could allow for a significant reduction.

posterior-temporal-reduction-by-muscle-removal-dr-barry-eppley-indianapolisposterior-temporal-reduction-incision-dr-barry-eppley-indianapolisUnder general anesthesia a straight 5 cm long scalp incision was made just above the ears. The temporalis fascia was split through which the entire posterior temporalis muscle was removed. Closure of the incision made for an inconspicuous scar line.

posterior-temporal-reduction-result-front-view-dr-barry-eppley-indianapolisBilateral removal of the posterior temporalis muscle bellies changed the shape of the sides of his head from convex to straight. With muscle thicknesses that average 7mms, bilateral removal can result in a transverse head width reduction of up to 1.5 cms. This demonstrates that temporal bone removal may not be necessary to achieve a visible head width shape change.


1) The wide side of the head is aesthetically determined by an increased convexity above the ears.

2) An increased head width above the ears is caused by both increased bone thickness  and muscle thickness.

3) Head width or temporal reduction is best done by removal of the entire belly of the posterior temporal muscle.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Anterior Temporal Reduction

Monday, August 15th, 2016


Temporal muscle removal has been shown to be effective at head width reduction. By removing the posterior temporal muscle belly, which is much smaller than the larger anterior temporal muscle and sits above the ears, a round or convex head shape can be narrowed. Interestingly the removal of this portion of the temporal muscle has no adverse effects on jaw function.

Temporal Muscle Anatomy Dr Barry Eppley IndianapolisBut for those who have a wide head width, the anterior temporal muscle may also be too thick. This creates a temporal convexity by the side of the eye in which a slight temporal hollowing is often aesthetically preferred. Such anterior temporal convexities seem to be an exclusive male aesthetic trait that is often seen in certain ethnicities. (e.g., Asians, Blacks)

The treatment of a large anterior temporal muscle is with Botox injections rather than surgery. Debulking the anterior temporal muscle is much more potentially problematic than that of the posterior temporal muscle. It is a hard area to access without more prominent incisions and the thickness of the muscle makes thinning it difficult.

One approach to anterior temporal reduction is that of a temporal lipectomy. There is an extension of the buccal fat pad that does reach up into the anterior temporal region. But it is often not that large and usually only affects the lower temporal region.

Anterior Temporal Reduction left side Dr Barry Eppley IndianapolisAnterior Temporal Muscle Reduction right side Dr Barry Eppley IndianapolisAn alternative approach is a high temporal release along the bony temporal line. This is the transition between the true bony forehead and the lateral muscular forehead. (high anterior temporal region) This distinct bony ridge is where the temporalis fascia attaches and the muscle ends. By disinserting the fascia and releasing the muscle attachments at this level, the temporal muscle will develop some atrophy and thinning. This will occur at the upper portion of the anterior temporal area and not down by the zygomatic arch. This can be done through a small scalp incision just behind the frontal hairline.

This high frontal approach to anterior temporal reduction is most appropriate for those patients who are bothered by fullness to the side of the forehead. It will not reduce temporal fullness down by the zygomatic arch where eyeglasses would traverse.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Minimal Incision Temporal Reduction Technique

Tuesday, November 3rd, 2015


Reduction of an undesired temporal convexity is becoming increasingly requested as it becomes aware that a procedure exists to do it. For a head that is too wide or convex above the ears, a technique has been developed to help narrow it. While such a temporal convexity is often perceived as being due to bone, the anatomy of the area indicates that the posterior belly of the temporalis muscle makes the greater contribution.

Resection of the posterior temporalis muscle can make a dramatic change in the shape of the side of the head. It can alter a convexity to a straight line as the thickness of the muscle is greater than one would think. In men the posterior belly of the temporalis muscle can be 7mm or more in thickness. Reduction of both sides of the head can thus result in a total width change of the head of up to 1.5 cms. Interestingly loss of the posterior temporalis muscle does not result in any loss of mouth opening.

Limited Incision Posterior Temporal Reduction technique Dr Barry Eppley IndianapolisLimited Incision POsterior Temporal Reduction technique 2 Dr Barry Eppley IndianapolisThe traditional method of posterior temporal reduction is done through a vertical scalp incision above the ears. Initially I made a 4.5 cm incisional length to remove the muscle. Having done the procedure many times I have been able to shorten the length of the incision down to 3 cms. This allows a subfascial approach to the head width in this area, reducing it by taking it out as a single piece of muscle.

left posterior temporal reduction result intraop dr barry eppley indianapolisTo demonstrate how effective posterior temporal reduction can be, here is an intraoperative view of the left side having been compared to the right side where the muscle still remains.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Temporal Muscle Reduction Migraine Surgery

Sunday, July 19th, 2015


Background: There are a wide variety of types of headaches of which migraines make up some of the most disabling. While the exact cause of many migraine headaches is not precisely known, certain types of migraines are known to occur from peripheral compression of certain cranial nerves. This has led to a variety of injectable Botox and surgical decompression surgeries to treat these very specific types of migraines.

One the of peripherally-based type of migraine headache occurs in the temporal region or the side of the head. Because the temporalis muscle is a chewing muscle such headaches often occur in people who grind their teeth due to stress. The zygomatico-temporal nerve branch (ZTBTN) comes through the temporalis muscle near the eye and can often be a source of temporal migraines. Treatment with Botox injections (diagnostic test for surgical treatment or simple avulsion of the nerve can produce noticeable improvement in the frequency and duration of these type of temporal migraine headaches.

Temporalis Muscle Reduction and Augmentation Dr Barry Eppley IndianapolisBut a false Botox test of the ZTBTN nerve or failure to produce a very pronounced reduction in the migraine headaches indicates that the compression of this small sensory nerve is not the true source of the problem.  The overall size of the temporalis muscle and/or its repetitive contraction could then be more likely the headache source. This can be confirmed by a clinical examination of clenching of the teeth, feeling the expansion of the muscle and palpating for the location of the painful stimulus.

Case Study: This 56 year-old female had a long history of temporal headaches that had been refractory to every conceivable treatment. She knew that it came from clenching her teeth and was persistent on the side of her head. Dental splints, drugs and ZTBTN Botox injections did not provide relief. Botox placed all over the temporalis muscle provided some improvement but the dose requirement (50 units per side) was high and only temporary. (less than three months)

Temporal Reduction Dr Barry Eppley IndianapolisUnder general anesthesia, the posterior portion of her temporalis muscle was removed through a small vertical incision. Both the fascia and the muscle were removed anteriorly to about 3 cms behind the temporal hairline.

At one year after surgery, she reported a complete elimination of her migraine headaches. She did not have a single headache since the surgery. Her incisions healed inconspicously and she had no short or long-term effects on chewing or mouth opening.

Temporal muscle reduction may seem like a radical solution to the treatment of temporal migraines. But as an end treatment in the refractory migraine headache patient, it is a simple procedure that has no adverse functional effects.


1) Temporal (side of the head) migraines typically responds to Botox injections, ZTBTN nerve avulsion or ligation of the temporal artery.

2) When the source of temporal migraines is related to clenching and large bulging posterior temporal muscles, muscle reduction can be effective for which Botox injections would be the first treatment approach.

3) Temporal muscle reduction of its posterior belly is an end stage migraine treatment that can be effective in the properly selected patient.

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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