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Background: The temporal muscle has a significant functional and aesthetic role to the entire side of the head. Its size influences the contour of the entire side of the head from the lateral orbital wall all the way to the parietal bone on the back of the head. It is one of the muscles that assists in the opening and closing of the lower jaw. To some degree the two are related…the stronger the muscle is in size and function affects how big it appears along the side of the head. The thicker/bigger the muscle is the increased convexity that can develop on the side of the head.

Men that have unaesthetic side of the head fullness, in which the temporal muscle is a significant cause, usually do not have any functional headache symptoms. They widely open their mouth and, as would be expected due to lengthening of the temporal muscle, their side of head contour improves as the thickness of the muscle becomes less. But a small subset of such patients do have headache symptoms in which the foci of the pain can be localized to the bulge of the muscle when they clench their teeth. This pinpoint location of the headache pain confirms that excessive temporal muscle contraction/tightness is the cause.

The treatment of both excessive temporal muscle thickness and temporal headaches can be done non-surgically with neuromuscular modulator injections. Botox is the most recognized injection drug and can have some positive benefits both in muscle size and headache reduction. But because of the size of the temporal muscle and its large surface area coverage it takes very high unit doses to create some benefits with similarly high costs to do so. While partially effective it is also not permanent with most patients achieving reductive effects of a few months in duration.                

Case Study: This male had a long standing history of unaesthetic temporal bulging associated with pain and headaches. He has received numerous high unit injections of Botox (up to 500 units) for treatment with some partial improvement in size and some headache reduction. But the cost to continue to do so was high and he sought a more permanent solution. On examination his temporal bulges improved by wide mouth opening confirming their muscular origin.

What was also unique about his examination was that the extent of the temporal muscle location was limited to where the bulge areas were located. The muscle did to extend over the much larger side of the head footprint.  

Under general anesthesia and through postauricular incisions, the muscle as located after going through the deep temporal fascia. It could be seen to have no posterior extension being this area. Through combined submuscualr and subfascial releases the muscle was rotated down bringing it a portion of it through the incision.

This muscle ‘excess’ was removed and the muscle transposed into a lower location by suture fixation. The deep temporal fascia was closed over the transposed muscle and the skin closed.

By doing both sides the temporal bulges were reduced and a smooth temporal contour maintained. (no muscle cut lines) 

Traditional temporal reduction consists of the entire removal of the posterior section of the temporal muscle through an oblique full thickness muscle cut. While very effective for most temporal hypertrophy patients, it is not ideally effective for those patients in which the bulging continues in the anterior segments of the muscle. This modified technique releases the muscle more anteriorly and then rotates it downward, removing a small section of the muscle that can be mobilized through the postauricular incision. The remaining muscle is then sutured down into a more inferior position. This avoids any potentially visible muscle cut lines and can now effectively reduce bulging anterior muscle segments as well.

Case Highlights:

1) Temporal muscle hypertrophy can cause unaesthetic side of the head bulges as well as refractory temporal headaches/pain.

2) Botox injections can decrease enlarged temporal muscles but the doses to do so are substantial, have a partial size and symptom reduction effect and is not permanent. 

3) Temporal muscle reductions/transpositions done through postauricular incisions can improve the contour of the side of the head and can reduce the severity of the headaches. 

Dr. Barry Eppley

Indianapolis, Indiana

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