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