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Posts Tagged ‘temporal implants’

Dermal Graft Temporal Augmentation

Tuesday, October 5th, 2010

The temple is a small and often unappreciated region of the face. The most visible part of the temporal region is situated between the side of the eye and the hairline behind it. It is vertically bounded by where it becomes part of the forehead (anterior temporal line) and the zygomatic arch below. (back part of cheek bone where it extends back to in front of the ear) It is primarily made up of the bulk of the temporalis muscle and its underlying fat pad. Normally, it is relatively flat not being too full or indented.

Cosmetic temporal changes do occur and they appear primarily as temporal hollowing or indentations. Too much temporal fullness can occur from overdevelopment of the muscle but this is quite rare. Temporal hollowing can occur from either muscle or fat atrophy. Disruption of the deep and middle temporal arteries is recognized as causing this ischemia. Well known causes are after surgical exposure of the area (neurosurgery or craniofacial surgery), radiation for intracranial malignancies, and traumatic injury. The other recognized causes of temporal hollowing are fat wasting due to automimmune diseases, retroviral medication, and malnutrition. But there is also a cosmetic temporal hollowing that has no obvious causes other than underdevelopment of temporal fullness, what I call congenital temporal hollowing. (CTH) There are some craniofacial syndromes where this occurs but it also appears merely as a cosmetic deformity.

In cosmetic CTH, there is an obvious indentation that is about the size of one’s thumbprint just to the side of the eye. (lateral orbital rim) It is not the size of what one would see from larger temporal hollowing from well recognized causes. But it creates a very visible cosmetic indentation that gives an hourglass shape to the side of the face. Correction of this form of temporal hollowing can be done by variation of traditional temporal augmentation procedures.

Traditional temporal augmentation procedures require extended scalp incisions and the use of some type of hard and soft tissue synthetic implant materials. But the smaller size of cosmetic temporal indentations do not justify these more invasive procedures. A minimally-invasive temporal augmentation procedure can be done that is both simple and very effective.

This limited temporal augmentation procedure uses a small 2.5 cm incision located just behind the temporal hairline at the level of the indentation. The incision ends up just below the frontal branch of the superficial temporal artery which is seen just above it during the dissection. The deep temporal fascia is incised and dissection is done in a subfascial plane underneath the indentation out to the lateral orbital rim. This dissection is below the level of the frontal branch of the facial nerve, which is in the more superficial temporalis fascia, so there is no risk of temporary or permanent forehead paralysis. This dissection is easy, quick, and could even be done under local or IV sedation anesthesia.

The critical question is what implant material to use. Since the material placement is on top of the temporalis muscle, just about any graft material would work including the full range of synthetic options.  But the use of a more natural or collagen-based material is appealing and the recipient site is ideal. I prefer the use of allogeneic human dermis of which many tissue bank providers exist. (e.g. Alloderm, Dermacell) With thicknesses of 1 to 1 ½ millimeters, it can be layered for increased thickness and cut to any shape. It is easily inserted in a flat or rolled configuration. Enough graft is placed to just slightly overbuilt it. The incision is closed with tiny dissolveable sutures. No dressings are used.

The results of the dermal graft temporal augmentationprocedure are immediate and very satisfying. There is no wound care needed with the incision in the hairline. One can shower and wash their hair the next day. There will be some mild swelling and occasionally a little bruising if the fascia attachments along the lateral orbital rim need to be released to get a smooth contour. With dermal grafts, the final volume outcome should await the six month after surgery time period. But their placement in muscle bodes well for long-term volume retention.   

Dr. Barry Eppley

Indianapolis, Indiana

Implant Options for Temporal Augmentation

Friday, August 21st, 2009

Temporal hollowing, also known as narrow or indented temples, gives the face (head actually) an unnatural hourglass shape. Rather than a convex transition from the side of the head into the upper cheek area, temporal hollowing shows a concave or sunken contour. Temporal hollowing occurs due to a variety of reasons. Most commonly, it occurs after neurosurgery where a long scalp (bicoronal) incision is used to perform a craniotomy either for tumors or skull fractures. It can also occur as part of certain diseases or medication use that causes facial fat loss. (e.g., HIV) Less commonly, it may also exist as one’s natural anatomy in thinner faces.

Such hollowing can be aesthetically improved through a procedure known as temporal augmentation. There are different materials and methods for changing the tenmporal contour from concave to convex.The key to choosing a successful augmentation method that has a low risk of complications is the condition of the temporalis muscle. Is the muscle completely normal as in the aesthetic patient or is it contracted and thinned from prior surgery or irradiation? The origin of the temporal hollowing, combined with physical examination, will reveal the condition of the muscle.

The temporalis muscle is a large fan-shaped muscle that originates from the temporal line of the skull and extends to insert onto the moveable lower jaw down below. Even in severe atrophy (shrinkage), the temporalis muscle is still moderately thick down near the zygomatic arch. The condition of the muscle higher up is where temporal augmentation takes place and is where the muscle may be most abnormal.

There is no implant material that is universally agreed upon for temporal augmentation. In cases of temporalis muscle atrophy, I prefer in my Indianapolis plastic surgery practice a bone-based approach to implant placement and try and get as much muscle pulled up over it as possible. I prefer a bone paste (hydroxyapatite cement) which is well tolerated and allows for intraoperative custom shaping. I have also used synthetic meshes (most commonly used in abdominal hernia repairs) folded into many layers to achieve the same effect. Given that the implant should ideally end up under the muscle, it is likely that the choice of material is not that important. Also, this type of temporal contouring uses a long scalp incision (which is likely already present from prior surgery) as direct vision and wide open access is needed for their placement and muscle resuspension.

Cosmetic temporal augmentation, however, is different. With a normal muscle, an implant material can be placed under the unscarred and normal fascia which covers the outer part of the muscle. Thus, a much smaller incision isolated to the temporal region can be used through which  a solid implant can be inserted. To keep the incision small, I prefer a silicone shell implant which is solid enough to slide into the subfascial plane and flexible enough to fit through a more limited incision. Cosmetic augmentations do not usually require as much ‘fill’ as a reconstructive one. It can be surprising how powerful an effect a relatively thin implant can be. Plus it is important to not overdo the size of the augmentation as a bulge is just as unnatural as a concavity.

There are some off-the-shelf temporal implants available from certain manufacturers but they are usually too large and require a lot of downsizing during surgery. They are more ideally suited to reconstructive cases of temporal hollowing after surgery. New temporal silicone implants are available that are more appropriate for the smaller hollowing in the cosmetic patient.

 Fat injections can also be used for cosmetic augmentation but are not appropriate for cases in which the temporalis muscle is not normal. In addition the survival of fat injections in the temporal area is highly variable and this is why a permanent implant in even a cosmetic patient is my preferred approach for temporal augmentation.

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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