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.
The 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.
But 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.
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.
For 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.
The 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.
Augmentation of the temporal region is a new area for synthetic facial implants. While every other facial implant designed is for bony augmentation, temporal implants provide enhancement of the soft tissue (muscle) region of the side of the forehead and eye. While injectable filler and fat provide a less invasive approach, they do not offer the capability of producing a one-time permanent solution to temporal hollowing.
The concept of a temporal implant comes from the historic repair of zygomatic arch fractures. Known as a Gille’s approach, depressed arch fractures are elevated from an incision in the hair-bearing temporal region and approached in a subfascial manner down to the bone. The path of dissection is on top of the muscle but under the fascia. It can be seen with the instrumentation that the entire temporal contour can be elevated from below. Thus it was logical to assume that an implant placed in the same location staying above the zygomatic arch would have an augmentative effect. The overlying temporal fascia seems flexible enough and the underlying temporalis muscle stout enough that the implant can push outward rather than inward.
The subfascial plane for a temporal implant is an easy one to surgically approach. And introducing the implant is equally easy. But one question that often comes up is what is to keep the implant from sliding down along the temporalis muscle, below the zygomatic arch and into the lower face? Not only has it never occurred but there are multiple anatomic reasons as to why that can not happen.
The first reason temporal implants have pocket stability is the anatomy of the subzygomatic arch space. While the bony arch does create a space or hole beneath it, the actual dimensions of the created space are less than the width of a temporal implant. As the zygomatic arch curves inward to attach to the temporal bone, it narrows the subzygomatic arch space. Thus when looking from above it can be seen that the front to back length of this space is shorter than the anteroposterior length of a temporal implant.
The second bony reason is the location of the coronoid process of the mandible. The tip of the coronoid process acts as an inferior stop as it juts upward into the subzygomatic arch space. In addition, onto the coronoid process are the funneled attachments of the temporalis muscle which also creates a soft tissue block.
For these anatomic reasons the temporal implant is prohibited from falling downward into an unintended anatomic location. The surgeon should feel comfortable making a pocket that is felt to be best for implant placement without this concern.
A recent news story out of the UK in London headlined the transfer of fat from a man’s stomach to his head to reshape it. Given that fat injections to the face, breast and buttocks have become so popular over the past decade, such a story is at the very least noteworthy.
The patient was a young 32 year-old man had some of his skull removed and surgery to reconstruct a shattered eye socket, cheekbone, and leg, following injuries sustained when he fell while climbing up a drainpipe outside his house. To ease brain swelling caused by his fall, a piece of his skull was initially removed which is standard practice in these type of injuries. Also he had titanium plates inserted to fix his broken eye socket and hold the bones together.Six months after his initial injury, the missing piece of his skull was reconstructedwith a computer-generated titanium plate based on the shape of his opposite normal skull. Despite restoring the bony shape of the skull, his temple area still remain indented. This is common after such skull procedures as the temporalis muscle, which needs to be raised off of the bone to perform the procedure, will shrink down in size during the healing process.
This ‘temporalis muscle atrophy after a craniotomy’ is well known and has been treated over the years by many methods. In this patient’s case, the surgeons used stomach fat harvested by ljposuction which was then injected into the temporal skull defect to fill it out for a smoother contour. How well the fat survived and adequately reconstructed the temporal defect months later was not described in the news story.
Reconstruction of a cosmetic temporal defect can be done with either a synthetic implant, allogeneic tissue grafts or fat injections. There are advantages and disadvantages to any of these approaches. Fat injections, just like they do for every other face and body application, offers a minimally-invasive procedure with a cannula harvest and a needle injection technique. Its disadvantage is in how much of the injected fat will survive. Experiences with temporal fat injections vary widely with some reporting good volume retention and others near complete absorption. I have seen both outcomes in my temporal augmentation with fat. For assured temporal augmentation results, a simple insertion of a specially-designed silicone temporal implant provides a permanent solution.
The temporal region of the face, technically the side of the head, occupies an often overlooked aesthetic area. It is bounded superiorly by the anterior temporal line of the forehead, anteriorly by the lateral edge of the bony brow and eye socket, inferiorly by the zygomatic arch and posteriorly by an indistinct margin in the temporal scalp hair. It is not a bony-supported region by rather one of soft tissue, the temporalis muscle and the deep fat pad. The temporalis fasciacovers the muscle and acts like a taut trampoline attached to the surrounding bony edges.
The aesthetic shape of the temple is determined by whether it has a convex, flat or concave appearance. There is no uniform standard or anthropometric measurement to judge what is its ideal shape. A flat or slightly concave temple area appears most common. A bulging or overlying convex appearance is unusual and unappealing and is rarely seen. An overlying concave appearance suggests a sickly or ill appearance. The shape and prominence of the forehead also influences how concave the temporal region will appear.
The most common aesthetic deformity of the temporal region is excessive concavity or depression. It can be caused from surgery (temporalis muscle wasting after a craniotomy), a medical condition (fat atrophy from extreme weight loss or medications) or one’s natural genetics. (congenital lipoatrophy) Regardless of its etiology, some form of an implanted material is needed to build out the temporal depression.
Methods for temporal augmentation have included injected fat, dermal grafts, bone cements or cranioplasty materials and various synthetic implants. Each has their own advantages and disadvantages and have different locations of placement, either above the fascia, below the fascia, intramuscular or on top of the temporal bone. Depending upon the cause for the temporal deformity, there may be benefits to one method of augmentation over the other.
While differing synthetic materials have been used, there has not been few if any preformed temporal implants available. A new preformed temporal implant is now available made out of flexible silicone rubber. Its shape mirrors the natural contours of the inferomedial bony boundaries where the greatest temporal concavity occurs. Its beveled shape allows differential augmentation to be achieved in an anteroposterior dimension so the augmentation is not too excessive near the hairline. Two different sizes are currently available.
Besides the innate flexibility of silicone, the implant is also designed with cross-cut ridges of material underneath to allow even greater three-dimensional implant adaptability. This could be a useful feature to allow the implant to not impede the excursion of the temporalis muscle with mastication.
In aesthetic augmentation, a temporal implant is best placed in the subfascial plane. This is easily done by a small vertical incision in the temporal hairline. This location allows the implant to be placed in a position that maximizes its shaped design. The curved form of this new temporal implant allows it to be rotated in through an incision that is smaller than its widest part. It can also be placed above the fascia but this places the frontal branch of the facial nerve at risk.
In augmentation of temporal defects from craniotomies, the temporalis muscle may be very scarred or severely atrophied. Placing it under the temporalis muscle in these craniotomy-induced defects may be preferable.
This new implant offers another treatment option for temporal hollowing. Its unique shape, flexibility and well-established tolerance to the material is a welcome addition to the expanding number of available cranial and facial implants.
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.