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)
Most 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.
After 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.
Background: The shape of the head has many aesthetic components to it not unlike that of the face. While no area of the head as the degree of aesthetic complexity that the face does, that does not mean that cosmetic concerns about specific areas of the head do not exist. They are less well known and treatments for them are even more obscure but public perception is increasing. The popularity of shorter haircuts and men shaving their head has given rise to an increased awareness of head shape concerns.
One aesthetic area of the shape of the head that is rarely discussed from a diagnosis or treatment corner is that of its width. The width of the head is created by the sides of the head which run from the superior attachment of the ear up to the temporal line of the skull. This area lies within the hair bearing area of the broader temporal region and is only composed of muscle (and fascia) and bone. While many think its shape is largely caused by the shape of the temporal bone, the reality is that the temporal muscle makes a greater contribution to its thickness than that of the bone.
While there are no truly established aesthetic standards for the sides of the head, some general guidelines can be used. A straight line or flat side of the head would be viewed by most as being too narrow. Conversely a significant arc or amount of convexity would be thought of as being too wide. It appears that a slight amount of temporal convexity is the most aesthetic shape when viewed from the front.
Case Study: This 35 year-old male had an underlying congenital skull deformity (most likely occipital plagiocephaly) which has been previously treated by occipital and anterior temporal augmentation. His lone remaining head shape issue was that he felt the very sides of his head were too narrow, more so on the right side than that of the left.
Under general anesthesia, performed posterior temporal implants were placed in a subfascial location on top of the posterior belly of the temporalis muscle. A small vertical incision in the hairline was used since he already had an existing scar there from prior surgery. The thickness of the preformed posterior temporal implants was 4mms. A good fascial closure as obtained over the implants prior to closing the skin.
His postoperative results showed a noticeable but not overdone head widening effect. The slight increase in temporal convexity gave his head a more pleasing shape with the noticeable fullness. He had no discomfort or restriction in opening his mouth after surgery as has been my experience with all subfascial temporal implants at either the anterior or temporal location.
1) The aesthetics of the side of the head generally have some degree of convexity or can appear as too narrow.
2) Subfascial posterior temporal implants can be placed to create an increased amount of head widening.
3) Generally 4 to 7mms of head width is all that is needed on each side to create a very noticeable difference.
The sides of the head, known as the temporal regions, is made up of the overlying temporalis muscle and the underlying temporal bone of the skull. What separates the temporal region on the visible outside is hair. The temporal hairline stops before reaching the side of the orbit leaving a strip of skin that runs from the zygomatic arch up to the forehead. This is an area that can develop the most visible temporal hollowing, is usually referred to when talking about the temples, but is what I call the anterior temporal region. Any part of the temporal region that lies in the hair bearing area is known as the posterior temporal region and extends back to behind the ear.
When desiring to augment or widen the side of the head, a comprehensive approach is needed to augment both the anterior and posterior temporal regions. This requires two separate temporal implants, one for each region which have different shapes. The anterior temporal implant is more high than wide. The posterior temporal implant is more oval shaped and is wider than it is high. They can be placed through the same vertical incision whose length is no more than 4 cms.
Subfascial placement of the anterior and temporal implants is done through the same incision. This is a simple dissection that does not disrupt or injury the temporalis muscle. Dissection of the anterior temporal region needs to extend superiorly to the anterior temporal line at the side of the forehead, down along the lateral orbital rim and inferiorly along the zygomatic arch. Dissection of the posterior temporal region must be carried over the entire extent of the posterior belly of the temporalis muscle, up to the temporal line, posteriorly to the occiput and inferiorly above the ear.
The temporal implants are easily slide into place and the fascia can be closed over the posterior end of the anterior implant and the anterior end of the posterior implant. Closing of the fascia is not mandatory, and is what will cause some temporary postoperative stiffness on oral opening, but creating a tissue layer between the implant and the skin always seems like a good idea.
Total widening of the head can be done using subfascial anterior and posterior temporal implants. They are straightforward to place and do not cause any undue amount of swelling or prolonged postoperative recovery. Typically most patients will look fairly normal in 7 to 10 days after the procedure.
Augmentation of the face through a variety of implants has been around for along time. Implant augmentation above the face on the skull bones is almost unheard of. Skull augmentations are much less commonly done, not only because they are less frequently requested, but because they are no implants made for them and surgical techniques taught to do them.
Some people have abnornally narrow skull shapes with the temporal region above the ears (what I call the posterior temporal zone) being non-convex. The typical aesthetics of the posterior temporal zone is to have some convexity due to the shape of the bone and the thickness of the muscle. When the temporalis muscle is thin or the shape of the posterior temporal bone is more linear than convex, the side of the head can look very narrow. This becomes most manifest in men with short cropped hair or who shave their heads. Although I have seen patients who have substantial hair cover who are equally bothered by it.
A head widening or posterior temporal implant is a very effective implant augmentation of this area. The implant can be placed either in the subfascial or submuscular location depending upon the incisional access. A vertical incision directly in the side of the head provides direct and easy access to subfascial placement of the implant. However such an incisional approach introduces potential scar concerns particularly with little to no hair color.
A postauricular approach is the ‘scarless‘ method for a head widening implant. With an incision in the crease of the back of the ear a submuscular pocket can be easily created. The pocket can be made from the very back of the posterior temporal region anteriorly to the front edge of the hair bearing temporal scalp. (anterior temporal zone) A posterior temporal implant can seem too large to fit through this small incision but the flexibility of a low durometer silicone implant makes it possible.
The posterior temporal implant must be folded onto itself, inserted and then unfolded once in the submuscular pocket. The pocket is fairly tight and the size of the implant makes it very unlikely that implant migration or displacement can occur. But I usually still place a single small titanium screw into the bottom of the implant for absolute security. It is critically important the closure of the postauricular approach re-estsblishes the muscle and fascia layers so the ear do not become protruding due to loss of its posterior attachments.
Posterior or head widening temporal implants can be placed through a postauricular incision into a submuscuar pocket. The implant usually does not need to be greater than 5mm to 7mms to great a substantial head width change when done on both sides of the head.
Facial implants are commonly used to augment various areas of the face. While historically this had been relegated to the cheeks and chin, their use has been widely extended to many other facial areas as well. One of the newer areas of facial implant use has been the temporal region for correction of excessive temporal hollowing or concavity.
Temporal implants are uniquely different from almost all other facial implants because they do not augment bone. Rather they are soft tissue implants that augment the amount of muscle volume that exists in the temporal region. What causes temporal hollowing is loss of fat volume and/or muscle, not a change in bone volume. While augmenting the anterior aspect of the temporal bone can be done, it would require a large implant placed very deep under the muscle to create that effect. It is far simpler and more effective to place a smaller implant right under the fascia on top of the muscle which is how newer temporal implants are done today.
Traditional temporal hollowing involves the lower half of non-hair bearing aspect of the temporal region just to the side of the eye. (lateral orbit) This is referred to as the Zone 1 temporal region. But other temporal areas can be augmented as well for different aesthetic effects. One of these is the Zone 2 temporal region. This is the upper half of the non-hair bearing area (above Zone 1) which is more to the side of the forehead than it is the eye. It abuts right up against the anterior temporal line of the forehead. Thus augmenting the temporal zone 2 creates a forehead widening effect.
Zone 2 temporal implants, like Zone 1, are placed under the fascia from a small incision in the temporal scalp area. While they are subfascial, the temporalis muscle gets very thin as it approaches the forehead. In addition, the underlying temporal bone no longer is concave but starts to become almost convex as it merges into the forehead. Thus a Zone 2 temporal implant is closer to being a bony augmentation technique rather than a purely muscle implant like Zone 1.
Widening the forehead has been traditionally very difficult. Extending bone cements from a forehead augmentation onto the temporalis fascia can result in a visible line of the material and discomfort. Fat injections can be done but their survival and smoothness if far from assured. Custom silicone implants can be made for forehead augmentation that extends onto the temporalis fascia to both augment projection and width of the forehead. But for those patients that just want a little more forehead widening only, there have been no options to date.
Zone 2 temporal or forehead widening implants offer s a simple and effective solution to those patients that would like to see just a slight increase in their horizontal forehead width. By placing an implant just to the side of the anterior temporal line under the fascia, the forehead can be made wider in appearance. This procedure, like Zone 1 temporal implants, has a very rapid recovery with little swelling and discomfort afterwards.
Background: Facial lipoatrophy is the loss of facial fat which has various causes. Genetics, aging, weight loss and side effects of medications can all create variable degrees of facial fat loss. While fat exists throughout the face in the subcutaneous plane and around the eyes, the largest concentrated fat depot is in the buccal space. It is this fat area that is mosts severely affected in all degrees of facial lipoatrophy.
Known as the buccal or Buchat’s fat pad, it is located deep in the face between various facial and masticatory muscles underneath the cheek bone. While it is called the buccal pad because of its primary location, it has numerous extensions or fingers into the pterygoid and temporal regions. Thus when loss of part or even all of the buccal fat pad occurs, temporal hollowing ensues along with submalar indentation.
The treatment of temporal hollowing is most commonly done by a variety of injectable filler materials. Hyaluronic acid-based and particulated fillers are office treatment methods while fat injections is more of a surgical approach. While these injection treatments for temporal hollowing can be effective, they are rarely permanent, may require multiple treatments, and are prone to irregularities and asymmetry.
Case Study: This 45 year-old male requested treatment for generalized facial lipoatrophy. One of his areas of concern was his very deep temporal hollows which were very concave and whose depth was well below the level of the zygomatic arch. This gave him a very skeletonized appearance across the bitemporal region.
Under general anesthesia (as he was undergoing various other facial procedures), small vertical incisions were made in the temporal hairline above the ears. After locating and incising the deep temporal fascial plane, blunt disection developed a pocket to the laterial orbital rim and along the superior edge of the zygomatic arch. Small soft silicone temporal shell implants were easily slide into the subfascial pocket, creating an instant temporal augmentation effect. The incisions were closed with dissolveable sutures.
Augmenting temporal hollows with a preformed implant creates a muscular augmentation effect unlike most facial implants whose aim is to create a bone augmentation effect. It is the soft tissue volume of the temporal region that is lost in facial lipoatrophy below the level of the subcutaneous fat beneath the skin. Thus it seems most logical to treatment the exact location of the tissue loss which is the temporal fat pocket beneath the temporalis fascia.
Placement of an implant in the subfascial temporal plane is a very easy dissection and pocket to create. This pocket location for the temporal implant requite no form of fixation as it can not migrate below the level of the zygomatic arch due to the narrow space behind the arch and the blocking effect of the coronoid process of the mandible below it.
Temporal implant augmentation offers a simple surgical solution that is both permanent, has yet to reveal any significant medical risks, and involves minimal discomfort and swelling. It has the fastest recovery of any of the facial implant procedures.
1) Temporal hollowing is a major manifestation of significant forms of facial lipoatrophy.
2) A soft silicone temporal implant is a new method to permanently correct temporal hollowing by muscle augmentation.
3) Temple implant augmentation is a simple surgery that has virtually no significant recovery or swelling associated with it.
Background: The head has a wide variety of shapes and sizes. Like the face, there are certain head shapes that are more pleasing than others. While one knows intuitively whether they like their head shape or not, there are certain measurements of height and width of the head that can help classify its beauty or conversely its degree of deformity.
Head and face measurements and their ratios have been studied for over 100 years in a field of scientific study known as anthropometry. Classic anthropometric measurements of the head are its length, width and cephalic index. The length of the head (front to back) is measured from the midpoint of the brow just above the nose back to maximal projecting point of the back of the head. The width of the head is from a point just above the ears from one side to the other. Taken together the cephalic index is derived which is obtained by taking dividing the width of the head by its length which creates a percent ratio. This number is almost always less than 1 since most normal human skulls are longer than they are wide. Based on their cephalic index, head shapes have been historically divided into three main types; long-headed (dolichocephalic, > 80%), medium-headed (mesocephalic, 75% to 80%) and round-headed (brachycephalic, < 80%)
The dolichocpehalic head is one that has a narrow head width. (which is compensated for by an increased head length) But there are certain head shapes that are narrow in their bitemporal width but do not have an increased cranial length. Their mid-temporal region slants inward as it ascends upward to the top of the skull rather than having a more aesthetically pleasing convex shape on the side of the head.
To date, there has not been any known method to safely and easily create aesthetic augmentation for increasing the width of one’s head should their bitemporal width be too narrow.
Case Study: This 35 year-old young man did not like the narrow width of his head. He felt his head was too narrow above the ears and it slanted inward rather than outward. This made his head ‘too small’ and disproportionate for the rest of his head and face shape. He wanted a wider head but did not want any visible scars in doing so given his close cropped hair.
While a 3D CT scan would have been ideal to make his custom temporal implants, he wanted to forego that extra expense. Using a standard male skull model, implant designs were done in silicone elastomer putty by hand with dimensions of 10 cms long, 8cms high and 7mms thick at its central location. The edges were made paper thin to have a smooth implant transition. The handmade temporal implants were converted into a medium durometer medical grade silicone implant and sterilized.
Under general anesthesia, skin incisions were made on the back of the ear in the depth of the postauricular sulcus. Dissection was carried down to the fascia and then superiorly under the lower edge of the temporalis muscle. Wide submuscular elevation was done over markings for the implant location that were made prior to surgery. The temporal implants were then rolled and inserted through the small incision and all edges unrolled once inside. The implants were then secured to the underlying bone at its lower edge with two 1.5mm titanium screws. The incision were closed in multiple layers, re-establishing the postauricular sulcus by dermal sutures to the fascia.
While he had some moderate temporal swelling after surgery, his pain was minimal. He had little recovery other than some swelling that resolved in a few weeks. His head width was instantly changed into a more convex shape which was very pleasing, adding 1.5 cms of bitemporal width. (Due to patient privacy, he did not want his before and after pictures published online. However he is willing to have them sent to anyone that wants to view them privately. You can request his before and afters by contacting me at firstname.lastname@example.org)
This type of temporal implants provide increased width and convexity for the narrow head. While custom temporal implants can be made from a patient’s 3D CT scan, the relative flat bony surface of the mid- and posterior temporal region makes a semi-custom approach a good treatment option. This new type of skull implant design provides another option in skull reshaping/augmentation that provides a different type of temporal augmentation that smaller more anterior-based implants for the non-hair bearing temporal hollow.
1) A narrow head is usually due to a bitemporal width reduction of the skull and/or muscle.
2) Custom temporal implants can be made to increase the bitemporal width from 5mm to 7mms per side.
3) Large custom temporal implants can be discretely placed through incisions on the back of the ears.
Temporal augmentation with implants is done by inserting them through a small vertical incision in the temporal hairline. They are placed on top of the muscle but below the overlying fascia. They are composed of a very soft and flexible silicone material that feels like soft tissue (muscle or fat) and not hard like bone. Different shapes and thicknesses of implants are available to best fill out esch patient’s temporal defects.
The following postoperative instructions for temporal implants are as follows:
1. Most temporal implant procedures have no discomfort. Patients usually only feel the need to use Tylenol or Ibuprofen for just a few days after the procedure, if any medication at all. You may also feel free to use ice packs on the temples for discomfort relief and swelling reduction the first night after surgery if you desire.
2. In all cases of temporal implants, there will be a circumferential wrap around the head for the first night after surgery. You may remove this wrap the day after surgery. It does not need to be used thereafter.
3. The sutures used in the incision in the temporal hairline will be dissolveable. There is NO need to apply antibiotic ointment on them. They require no topical care.
4. You may shower as normal the following day and you may wash your hair as normal 48 hours after surgery. There is no harm in getting the temporal suture lines wet.
5. Temporal implants may cause some swelling and bruising the eyelids or cheeks in some patients. You may was your face and apply make-up over any bruised areas the following day.
6. There are no limitations to any physical activities after temporal implant surgery. You may feel free to run, workout and do any non-contact sporting activity as soon as you feel comfortable.
7. You may eat and drink whatever you like right after surgery.
8. You may drive the next day after surgery when you feel comfortable and are not on any pain medication.
9. You may wear regular or sunglasses when the temporal swelling permits and it feels comfortable to do so.
10. If any temporal redness, increased tenderness or swelling, or incisional drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.
Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of temporal implant augmentation. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.
Alternatives for improving the appearance of a depressed or hollowed temporal area include synthetic injectable fillers, fat injections, or augmentation using a variety of bone cements.
The goal of temporal augmentation is to improve its appearance from a hollowed (concave) profile to a flatter one. In rare cases, the patient may even have a more convex profile if they desire.
The limitations of temporal augmentation with implants is the size and shape of the implanted material. The thickness of the implant and its height and length determine how much augmentation is achieved.
Expected outcomes include the following: temporary swelling and bruising around the temples and eyes, temporary numbness of the overlying temporal skin, and four to six weeks after surgery to see the final temporal shape.
Significant complications from temporal implants are extremely rare. More likely risks include infection, permanent temporal hairline scars, overcorrection or undercorrection of the temporal profile, and implant/augmentation asymmetry. Any of these risks may require revisional surgery for improvement.
Should additional surgery be required for temporal implant revision and/or replacement, this will generate additional costs.
Soft tissue augmentation of the face has gained popularity due to the use of a wide diversity of injectable fillers. From synthetic materials to fat, any soft tissue zone of the face can be injected. While facial implants have been around for many years for hard tissue augmentation, such as the chin, cheeks and jaw angles, there are many more soft tissue zones than there are hard tissue ones.
One of the facial soft tissue zones that has become possible to reliably treat is that of the temples. The temporal zone is very much like the submalar-lateral facial zone in that it is a ‘trampoline’ facial zone. It is surrounded by bony margins that support skin and underlying fat and muscle. The superior margin is the anterior temporal line, the transition area into the bony forehead. Its anterior margin is the lateral orbital wall and its inferior border is the zygomatic arch. Its posterior border is not significant in most cases because it is obscured by the hairline and temporal scalp.
The contour shape of the temples is primarily influenced by how much fat and muscle lies underneath. Skin laxity is not an issue. Most commonly there is a slight concavity to the temples. But too much concavity or even excessive convexity is obvious and disrupts the shape of the overall face. How much temporal concavity is aesthetically acceptable is a matter of debate and belies any known established measurements. But when excessive the bony margins become obvious and presents an appearance of aging or even illness.
I have observed that placing a ruler or straight instrument between the anterior temporal line and the zygomatic arch, most people will have 1 to 3mms of concavity at the central or deepest area of the temples. When it exceeds 5mms or more, most people would view it as excessive temporal concavity.
For temporal hollowing, the most common treatments to date are injectable fillers. Treatment options include hyaluronic acid, PLLA and HA fillers as well as fat injections. Most of these injectable fillers are placed in the subcutaneous space between the skin and the superficial temporalis fascia. While this is where the frontal branch of the facial nerve passes, the risk of injury is low. Some do place fillers directly under the fascia into the temporalis muscle but this is less commonly done. In theory the muscle is a better place for longevity of fillers, particularly that of fat, but the push on the skin from under the temporalis fascia is weakly transmitted because the stiffer fascia pushes back against the soft filler.
While injectable fillers can be effective for temporal hollowing, they are not permanent and the volume needed for a single treatment is costly. It usually takes 2ccs of filler per side to have a visible effect. An alternative treatment for temporal hollowing is that of a synthetic implant. Made out of a flexible and very soft silicone material, temporal implants are inserted under the deep temporal fascia. It produces a result that is more significant that any injectable filler treatment and will create a permanent augmentation.
The surgical technique for placement of a temporal implant is very simple and can be done under local anesthesia if desired. Through a small vertical incision in the temporal hairline, the deep fascia is incised and the pocket quickly and easily made. Different sizes of temporal implants exist depending upon the depth of the concavity and the use of preoperative sizers. Adjustments to implant size can be easily done by trimming with scissors. There is no need for implant fixation as the pocket on top of the muscle controls its position. There is minimal discomfort afterwards and no bruising. The swelling is mild and there is no discomfort on chewing.
The simplicity and the permanence of specific shapes of synthetic facial implants should be considered as an option for the treatment of aesthetic temporal hollowing.
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.