Background: The aesthetically wide head is typically seen as a pronounced convexity in the temporal regions of the skull. While much of the skull is compromised of bone under the scalp, the temporal regions which make up the sides of the head are unique in that regard. While there is temporal bone a significant part of its thickness is muscle. The muscle thickness can vary from person tom person as well as amongst different ethnicities. But it is fair to say in my experience that it is at least 50% of the width for most people. As a result the wide head and the convexity seen has a major component of muscle to it. Successful management of the wide head therefore has to have a strategy for muscle thinning. (temporal reduction)
When it comes to temporal (head widening) reduction there are 4 types. Posterior temporal muscle excision (Type 1) and posterior temporal muscle excision with anterior temporal muscle transposition (Type 2) are performed through a hidden scar behind the ears. (postauricular sulcus) Type 3 temporal reduction uses an incision along the sides of the head for posterior temporal muscle excision, anterior temporal muscle transposition as well as temporal bone burring reduction. Type 4 is the maximal head widening procedure in which every component is addressed to the maximum with posterior temporal muscle excision, anterior temporal muscle release with mid-wedge excision as well as lateral bony forehead/temporal line and temporal bone burring reductions. This maximal head widening approach is done through a transcoronal scalp incision.
Case Study: This male had long been bothered by his head size which he felt was too wide. Circumferential head measurements confirmed his perception as anytime these numbers exceed 60cms the head is going to be seen as big. (normal male head circumferences are in the 57cm range) But beyond these numbers what counts is how the patient sees it. Despite his thick and curly hair coverage his head width could be seen to be wide. The temporal muscle bulging could be both seen and palpated particularly in the anterior non-hair bearing region. The width of the bony forehead could also be seen to be wide. Given the bony and miscue widths it was felt that only a Type 4 temporal reduction would be effective. He was more than willing to accept the scalp scar to do so. Using computer imaging the goal and expected change was shown.
Under general anesthesia a transcorocal scalp incision (with no hair removal) was made through a very thick and vascular scalp. The skull bone centrally and the temporal muscles on each side at the deep fascial levels were exposed. The bulging shape of the muscles could be easily seen. (typically they are flat in shape with no bulging)
The fascial covering was vertically opened and the entire left posterior temporal muscle removed. Its thickness down by the ear was almost 15mms. The exposed ‘blunt’ posterior edge of the remaining anterior portion of the muscle was thinned out and a ‘corset’ fascial closure done.
The identical posterior muscle excision and closure was done on the right side. One closed the anterior muscle was treated by opening the fascia in its mid-portion and taking a central wedge of muscle thickness on both sides.
The fascia was then closed on both sides reducing the anterior muscle bulging on both sides to a flatter profile.
As the last step in the procedure the anterior muscle was released along the bony temporal lines and the sides of the bony forehead and the prominent of the temporal lines reduced.
Over drains the scalp was closed in two layers (fascia and skin) using a double comb technique to meticulously put together the top scalp layer with fine 5-0 plain sutures.
While time and healing will reveal the final aesthetic change, the internal reduction in the width of the head could be appreciated intraoperatively.
While a type 4 temporal reduction achieves maximal head width by muscle and bone manipulations the aesthetic tradeoff is the scalp scar. Whether the transcoronal scalp scar is worthy of the most that can be achieved in head width reduction surgery is an individual patient decision. Suffice it to say that such an aesthetic tradeoff is likely more acceptable in a patient with hair.
Highlights:
- A very wide head is the result of large temporal muscle hypertrophy and associated widening of the bony forehead and temporal lines.
- Type 4 temporal (head) reduction employs wide open access using a transcoronal incision for both muscle and bony reductions.
- Despite the severity of its appearance the type 4 temporal reduction is not associated with substantial more swelling or recovery than Types 1 – 3.
Dr. Barry Eppley
World-Renowned Plastic Surgeon