How Can The Hollowing In My Temples Be Improved?

Q: I have these indented areas to the sides of my eyes that bother me tremendously. My temples are sunken in and I have to style my hair to keep them covered. I read in one your blogs that a temporal augmentation procedure can be done to built these areas out. I would do just about anything so I could wear my hair back and not have to spend some time making a styling effort to keep them hidden. I have attached some pictures which show the areas of the temples that bother me. Tell me what you think can be done. Do you think the temporal augmentation procedure will work for me?

A: Thank you for send these very well illustrated photos. I could not have drawn the problem or photographed it any better myself. In studying these different angles, your temporal issues are fairly unique in terms of location. They are located not primarily in the hairline (or substantially there) but anterior to the temporal hairline extending right up against the lateral orbital rim of bone of the eye. They are not large (but skull defect standards) but are deep and very apparent. I can certainly see your esthetic concerns with them.

Because of their location, they pose one unique consideration for temporal augmentation…the location of the frontal branch of the facial nerve. This nerve branch runs right through the middle of that area on its way to the forehead. It is responsible for forehead movement, its paralysis is like having a permanent Botox effect. Therefore, one must be careful to not risk injury to that very sensitive nerve branch. Anatomically, it lies between the underside of the skin and the temporal fascia.
In considering augmenting this temporal  area, it can be done from three different anatomic layers….subcutaneous (under the skin), subfascial (between the fascia and the muscle, and submuscular. (deep under the muscle. Because of that branch of the facial nerve, I would avoid putting anything into the subcutaneous space. While that space offers the most effective layer for augmentation, because it pushes out the skin the best as it is closest to it, the risk of nerve injury is not worth it.
This leaves us with the options of subfascial and submuscular layers for implant placement. I would prefer the subfascial as it is an easier and less traumatic place to get into to surgically. The submuscular plane, also known as the pterional location, is usually reserved for temporal augmentation when the temporalis muscle is already lifted up during a neurosurgery or craniotomy procedure or if one already has a bicoronal scalp scar. The subfascial plane protects the facial nerve while sitting on top of the muscle.
The next question is what type of implant to place there. Fundamentally, the options come down to either a synthetic material (such as silastic or gore-tex based) or a allogeneic dermis. (sterile cadaveric dermis which is widely used for facial augmentation) The implant has the benefit of never resorbing but is a synthetic material. The dermis has the advantage of being very soft and will integrate into your tissues (beceome part of you) but may develop some resorption. As you can see, each type has specific advantages and disadvantages. I am leaning towards the synthetic implant because of volume stability but the dermis product is always appealing because it is so soft and is a collagen-based material. (not synthetic)
Either way, a small incision would be made behind the hairline and would be vertically about the height of the temporal defect. It is not a long or complicated procedure (1 1/2 hours) and would be done under general anesthesia as an outpatient. There would be some temporal swelling but likely no bruising. You may likely notice for a few weeks some stiffness on widely opening your mouth.

Dr. Barry Eppley

Indianapolis, Indiana