Implants provide a permanent method for augmentation of temporal hollowing. Placed at the sub fascial level they create a muscle augmentation effect as an interpositional material between the muscle and the overlying fascia. As of today there are two styles of standard temporal implants. For hollowing that is limited to the lower half of the temporal area there is a style one design. When the temporal hollowing extends all the way up to the bony temporal line of the forehead there is an extended design known as style 2 which has a more vertical elongated implant footprint.
Regardless of the temporal implant style they are both placed through small incisions behind the temporal hairline. But despite the same incision location there are different considerations in their placement to get the correct orientation. In the style to extend it Templeton plant it’s Long height and relatively short with poses challenges for placement. Coming in from a side incision provided adequate suibfascialpocket dissection has been done the implant must pass through the incision and then turn 90° for proper implant orientation. Unless one is coming from a very high temporal hairline incision the style 2 temporal implant can not be placed like putting a pizza in the oven.
As a result of this implant placement requirement it is not uncommon to see malposition of the style 2 temporal implant. In replacing malpositioned temporal implants the existing implant can be readily removed due to the non-adherence of the capsule to the implant. The pocket can then be adequately extended and a new implant placed in a better position. However since there is no method of securing a temporal implant into place other than the size of the pocket there can be a great propensity in replacements to have the new implant slide out of its new position back into its previous pocket with recurrent malposition.
While the most effective strategy for preventing this problem is internal capsular suturing the incision used in temporal implants does not usually make this possible to any significant degree. An alternative strategy to closing down the large temporal implant pocket is an external bolster technique. Once the new implant is in place a suture is passed through the skin down through both sides of the now empty implant pocket area and then back out through the skin. Both suture ends are then tied over a bolster. The bolster can be made of a preformed dental roll or rolled Xeroform gauze. The bolster is left in place for 5 to 7 days so that enough healing occurs that recurrent implant malpositioning is much less likely to occur. The bolster also has the benefit of helping reduce the amount of postoperative swelling.
The over enlarged pocket from prior temporal implant malpositioning may be able to be reduced by the placement of internal sutures. But the size of the temporal incision is limited for much internal suturing particularly very far past the incision entrance. The bolster technique provides a greater ability to close down specific areas of the pocket. As long as the application of the bolster does not go much past the edge of the temporal hairline there is no risk of frontal branch facial nerve injury.
Dr. Barry Eppley
World-Renowned Plastic Surgeon