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Posts Tagged ‘temporal reduction’

Case Study – Head Width Reduction

Saturday, April 2nd, 2016

 

Background: The perception of excessive head width is usually seen as a convex shape to the side of the head above the ears. This makes the side of the head bow out and gives the overall head shape more of a ‘lightbulb’ appearance particularly when the lower facial features are smaller and more narrow. There may also be other aesthetic issues besides its appearance such as having trouble wearing glasses or hats that feel too tight.

Temporal Muscle eductionThe width of the head is comprised of the temporal bone and muscles. The widest part of the side of the head is the posterior temporal area above the ears. While it is commonly perceived that any such bowing is largely due to the thickness of the posterior portion of the temporal bone, this is an anatomic inaccuracy. While the bone does make a significant contribution, the thickness of the posterior belly of the temporal muscle makes up at least 50% of its width. This can be appreciated by looking at coronal images of a CT scan where the thickness of the muscle can be better appreciated. In my experience it usually measures anywhere from 7 to 9mms in thickness above the ear.

Removal of the posterior portion of the temporal muscle can create a very visible reduction in head width. I have performed it many times and have come to appreciate both its effectiveness and safety. Removal of this portion of the temporal muscle is not associated with any chewing or mouth opening difficulties. Surprisingly most patients do not even have any stiffness or soreness of mouth opening even the day after surgery.

Since a significant percent of patients seeking head width reduction are men, often with close cropped hair or a shaved head, the relevance of any visible scars from this procedure is an important aesthetic issue.

Case Study: This very young male had long been bothered by the shape of his head. He felt it bulged out at the sides and make his head too round for the shape of his face.

Posterior Temporal Zone of Wide Head Dr Barry Eppley IndianapolisTemporal Reduction by Muscle Resection intraop Dr Barry Eppley IndianapolisUnder general anesthesia, the posterior temporal zone of muscle removal was marked out. Through a postauricular incision and in a subfascial plane, the entire posterior portion of the temporal muscle was removed. The overlying deep temporal fascia was left intact. The incision behind the ear was closed with dissolveable sutures.

Head Width Temporal Reduction early results front viewHead Width Temporal Reduction early results back viewHis immediate surgery results (one day later) showed a visible reduction in the width of his head. Further swelling reduction would be expected to enhance the result over the next month. He had no chewing pain or mouth opening restrictions. He had some ear swelling which made his ears protrude slightly more than they did before surgery. This is a self-solving issue as the swelling subsides.

Head width reduction by posterior temporal muscle removal can be done successfully without visible scarring in the temporal region. Two key surgical techniques are keeping the overlying fascia intact and re-establishing the attachments of the ear to the side of the head during closure.

Highlights:

1) Excessive head width often refers to a fullness or convexity above the ears.

2) A substantial amount of excessive head width is due to the thickness of the posterior temporal muscle

3) Head width reduction can be achieved through removal of the posterior temporal muscle through an incision limited to behind the ear.

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.

Highlights:

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

Technical Strategies – Scarless Approach to Temporal Reduction

Tuesday, May 5th, 2015

Reduction in the width of the side of the head (head narrowing) is most commonly done by removal of the posterior belly of the temporalis muscle. Many people understandably think that the width of the head above the ears is mainly due to bone but that assumption is usually incorrect. While the bone makes some contribution the more significant tissue adding to the protrusion is the thickness of the muscle. At thicknesses of 7 to 9mms in many patients, reduction of the muscle can make a dramatic change in the bitemporal distance of up to 1.0 to 1.5 cms.

Vertical Incision Temporal Reduction Dr Barry Eppley IndianapolisMy typical approach to temporal reduction has been through a vertical incision above the ear. The incision is about 4 to 4.5 cms long and runs about halfway towards the superior temporal line. While this temporal scalp incision usually heals very well and often in an indiscriminate manner, there is always risk of some visibility of the scar particularly in those men that shave their heads or have very closely cropped hairstyles.

Scarless Approach to Temporal Reduction Dr Barry Eppley IndianapolisPostauricular Incision for Temporal Reduction Dr Barry Eppley IndianapolisA completely hidden scar approach to temporal reduction is to place it behind the ear in the postauricular skin crease. This incision allows direct access to the thickest part of the posterior temporal muscle above the ear and permits additional muscle removal above and behind it. Whatever muscle it can not reach from the incision will atrophy and shrink down later as the muscle in front of it has been removed. Some temporal bone reduction can also he done within a range of 3 to 5 cms from the superior end of the incision.

Postauricular Incision Closure for Temporal Reduction Dr Barry Eppley IndianapolisClosure of the postauricular incision with resorbable sutures results in a very fine line scar in an undetectable location. This temporal reduction approach takes no more time to complete and makes it a more palatable option for many male patients.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Temporal Reduction in Head Narrowing Surgery

Monday, December 1st, 2014

 

A head that is too wide is marked by excessive convexity in the posterior temporal region above the ears. Often the width of the skin (even without hair) may stick out as much as the projection of the ear…and in some cases even more than that of the ear.

There is no question that the width of the temporal and parietal bone makes a contribution to head width but often less so than one would think. The thickness of the posterior limb of the temporalis muscle can be very thick, often as much as 7mm to 9mm in some individuals. The muscle does taper considerably as it reaches to the parietal region but the width of the head is often judged in a more anterior temporal position.

Skull Burring for Head Narrowing Dr Barry Eppley IndianapolisWhen attempting to  reduce the width of the head (bitemporal/biparietal distance), it is usually necessary to do a combined muscle and bone reduction. Removing the entire posterior limb of the temporalis muscle causes no functional sequelae and can result in a full cm of width reduction between the two sides. Burring down the temporal bone is not as productive in regards to width reduction but still has a valuable role to play. The bone can usually be reduced up to 3 mm to 4mms per side. It is important to reduce the temporal bone up high, taking down the temporal line so the head shape does not become too boxy and square.

Head narrowing surgery can be moderately successful using a combined muscle and bone reduction technique. It does require at least a vertical incision above or behind the ear or can be done as part of a full coronal incision based on other concomitant craniofacial or skull reshaping procedures being done.

Dr. Barry Eppley

Indianapolis, Indiana

Aesthetic Reduction of Head Width by Temporalis Muscle Resection

Thursday, June 19th, 2014

 

Head shape is an aesthetic feature that is often overlooked or disregarded…unless one has a head shape that they do not like. While the shape of the head does usually play second fiddle to the shape of one’s face, they are inter related and the appearance of one can affect the other. Many assume that the shape of the face is the same as that of the head, and in many people this is true, but it is not always so.

One aesthetic head feature is that of width. The width of the head is largely perceived as the bitemporal width. At its widest this is an area just about the ear from each side of the head. This is composed largely of the temporal bone and a portion of the anterior parietal bone and the posterior portion of temporalis muscle. This occupies the space from the base of the ear vertically upward to the anterior temporal line where the muscle transitions into more horizontally oriented skull bone.

Temporal Muscle Anatomy Dr Barry Eppley IndianapolisWhile craniometry has numerous numbers for normal head width, this is as much a personal aesthetic judgment as any measurement. Heads that are seen as too wide all have a convexity to their shape that usually impinges on a vertical line that extends upward from the top of the ear. Many assume that this is due to the shape and thickness of the underlying temporal bone. But the reality is that the thickness of the muscle usually plays a more major role in the shape and thickness of the side of the head that does the bone. The location and thickness of the temporal muscle in its more posterior origin above and behind the ear is frequently underappreciated.

Aesthetic reduction of excessive temporal width, or a wide head, is often most effectively done by a temporal muscle reduction technique. Removing the posterior portion of the temporalis muscle can change the shape of the side head quite dramatically.The addition of bone reduction underneath it can be done at the same time but it has a more minimal reduction effect than that of the muscle

temporal muscle exposur tthicknessThe surgical technique for aesthetic temporal reduction is done through a vertical scalp incision above the ear that has a length of no more than 7 cms. Hair is not shaven to make the incision, it is just parted by making it wet. The incision parallels the hair follicles and goes down to the galea. The galea is incised with electrocautery and the deep temporalis fascia plane exposed.

temporal muslce excisionThe thickness of the temporalis muscle is usually between 5 to 7mms including the fascia. But in really convex head widths, it can be even thicker. With electrocautery in an oblique orientation from the ear going upward toward the anterior temporal line, the muscle incised all he way down to the bone. From there on back the entire posterior muscle is removed. The edges of the cut muscle are cauterized so they retract back under the fascia along the open edge. When done bilaterally, the reduction in bitemporal width can be between 1 to 1.5 cms. and the side of the head shape changed from convex to a perfectly straight line.

temporal muscle reduction incisionThe temporal scalp skin is then closed in two layers, galea and skin. Small resorbable sutures are used and the hair combed back over the incision, making it an undetectable incision line.

The logical questions about posterior temporalis muscle removal are functional in nature…if we don’t need it why is it there? As it turns out there are no functional issues caused by its excision. No patient having the procedure has had any mouth opening or closing problems. In fact not one has even had any slight pain on jaw movement. It appears that the much larger anterior portion of the temporalis muscle is the real work horse of jaw function.

Aesthetic reduction of the sides of the head can be safely and effectively done by removal of the underlying temporalis muscle. It is a very simple procedure that can be done in one hour under general anesthesia. There is minimal recovery and very little discomfort afterward.

Dr. Barry Eppley

Indianapolis, Indiana

Functional Implications of Aesthetic Temporal Muscle Reduction

Friday, April 25th, 2014

 

Temporal Muscle Anatomy Dr Barry Eppley IndianapolisThe temporalis muscle is the largest and most powerful muscle of the face and skull. It runs from almost to the back of the head down below and behind the cheek bone to attach to the lower jaw. It can be seen to have two parts. The anterior or front part runs almost vertically and moves the lower jaw forward (protrudes the lower jaw). The posterior part of the muscle above the ear runs almost horizontally and pull the lower jaw backwards. If both parts of the muscle are activated, it causes one to bite down. This is the classic functional and anatomic description given to the temporalis muscle seen in any anatomy textbook or article.

It is the posterior part of the muscle that has aesthetic relevance as it relates to the perceived width of the head above the ears. The posterior temporalis muscle in this area can be surprisingly thick, often 5 to 7mms in thickness. (in not more in some men) Reducing or removing the posterior temporalis muscle can make a very noticeable change in head width, bringing in the sides above the ears considerably. While this is an aesthetic benefit, it would seem that removal of the posterior part of the muscle would cause problems with bringing in the lower jaw during closure. (per anatomic descriptions as previously noted)

Temporal Reduction Dr Barry Eppley IndianapolisBut the reality is that removal of the posterior temporal muscle appears to have no negative functional repercussions. Having performed many posterior temporal resections for head width concerns, I have yet to have one patient who has had a single muscle symptom. Not even a single case of immediate after surgery trismus. (difficulty with opening one’s mouth or temporary mouth opening stiffness) Such clinical findings run counter to classic teachings. But it actually is consistent with a long-standing finding in an another surgical specialty…neurosurgery. It is not rare to see patients after a temporal craniotomy (and most severely seen when combined with radiation) to have severe temporal hollowing. (muscle wasting) But yet they rarely if ever have any mouth opening or stiffness problems.

Aesthetic temporal reduction by muscle removal (myectomy) is a safe and effective procedure. Despite what one would anatomically expect and is written, the posterior segment of the temporalis muscle can be completely removed without causing any dysfunction of jaw movement.

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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