Q: Dr. Eppley, I am interested in temporal and brow bone augmentation. I was wondering what you would suggest for a 26 year old patient with weak temple and brown bones that make me look tired. I want the brow and temple area to be smoother and flatter and my eyes to look less protruding. I was reading about fat injections and was wondering if those can give me the results or would I need something more extreme like implants.
A: Thank you for sending your pictures. For the temporal region I can see where our extended anterior temporal implants will fill out the temporal areas nicely up to the temporal lines of the forehead. Building out the brow bones (supraorbital ridges across the top of the eyes would make the actual eyes look less protruding. The best way to achieve that look would be to make a custom brow bone implant for you off a 3D CT scan. Both procedures could be done concurrently. The temporal implants are placed through small (3.5 cm) vertical incisions back in the temporal hairline. The brow bone implants could be placed endoscopically through small scalp incisions.
The problem with fat injections, particularly for the brows, is that they are unpredictabe in terms of survival. In addition they produce very ‘soft’ push on the outside tissues which may be acceptable for the temples but not for the brows. But as an alternative and potentially more appealing treatment strategy this can certainly be done. And there is little to lose but doing so.
In reality, the placement of implants is not much traumatic than doing fat injections in these areas.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in temporal augmentation but I have questions regarding it and how it may be used for hollowed temples and cheeks on one side of the face. It appears to myself that the areas where the buccal fat pad would sit on one side of the face is abnormally thin. This contributes to a visibly old-like or sick appearance one one side of the face, but the other half looks healthy and normal for a young adult. My concern is more so on the temples than the cheeks. Is there enough protection of the temples on that side? (are there concerns regarding temple injuries) It also concerns me that I look “unhealthy” and abnormal because of it. What do you suggest for my temporal augmentation? Thank you for your time.
A: Temporal augmentation surgery is very safe and there are no concerns about ‘temple injuries’. Temple augmentation is about developing an increased muscular appearance using either implants placed in the subfascial location or fat injections directly into the muscle. Each temporal augmentation method has advantages and disadvantages with the primary difference being one has an assured permanence (temporal implant) while the long-term fate of fat injections can be more variable.
Dr. Barry Eppley
Q: Dr. Eppley, I should start by saying thanks for the temporal implants two months ago. They really seemed to do the trick, at first. For the first ten days or so I was thrilled with the results, but I didn’t realize how much of the fullness was due to swelling. Now it has been nearly 2 months and I can assume the shape is final.
I’ve attached a picture (series of 4 pics) that illustrates the situation. The second image is 48 hours after surgery, you can see the ideal fullness is there, especially on my right temple (and from what I can feel, the implant on the right feels/looks thicker than the one on the left). The last 2 pictures on the right are from two months later. As you can see, the swelling has faded and the implants don’t quite fill out the space entirely. They do a nice job filling out the hollowing near the bottom, but they fade out up higher and the classic temple defining shadows/lines returned.
I do realize the results are significantly better than the “before”, that I am grateful for, but I’m wondering if you have bigger implants available than what you gave me. They would also have to maintain thickness as they travel up towards the hairline. Something that would give me a final result that matches the 48 hour picture. Maybe that means making them convex, I don’t know. Is it even possible to replace them? I am just trying to figure out what my options are, if any. Thanks
A: Thank you for the follow-up. The reason the temporal implants don’t reach what I can Zone 2 of the anterior temporal region is that they can’t. They are not made to go up that high. They have a superior height of 4 cms, which means their greatest reach vertically will be 4 cms above the zygomatic arch with the last centimeter being tapered to avoid an obvious step off. (so they really only augment significantly 3 cms above the arch) There are no temporal implants that will extend all the way up to the anterior temporal line. Custom ones can be made to do that if desired but such large (vertically high) temporal implants are not standard or stock styles that are commercially available. It is relatively easy to replace your existing temporal implants with larger ones. It is not a surgical issue, just a design issue to overcome.
Your issue is not rare in temporal augmentation which is why I am currently working on extended temporal implant designs that can reach all the way up to the anterior temporal line by the forehead.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in making my forehead wider and more squarer to balance out the width of my new custom jaw implants that will be placed in about a months time. I have booked in for temporal implants at this stage but not forehead as I don’t think my doctor or any doctors here are quite familiar with the procedure. I wanted to know if it is ok to request to my doctor to use Medpor temporal implants? This is because I had a look at the Medpor catalogue and have found that the Medpor brand offered a significantly BIGGER size compared to the silicone ones offered my Implantech (which my doctor will use). Medpor ones go up to 20mm in augmentation. I’ve read your resource millions of times (very helpful) and want to know do temple implants sit only on top of the soft tissue or can the implant itself be placed higher if the implant overlaps onto the bone? Or is that something a custom made forehead implant would fix? If so are there any off the shelf forehead implants available on the market to widen the forehead?
I also wanted to know if I was certain that I need a forehead augmentation in future are temporal implants necessary? Or are they needed along WITH forehead augmentation. I just don’t want to waste my money on temple implants if a custom made forehead implant will fix both areas.
A: I would never use Medpor temporal implants myself. They are too big, are very difficult to modify and are very difficult to remove should that ever be desired. (and there should be a high probability that they would) No one ever needs a temporal augmentation that requires a 20mm thick implant. They are simply too big for most cases and were initially designed for patients that suffered significant temporal muscle atrophy from neurosurgical procedures not for patients that want a pure aesthetic augmentation with a normal tenporalis muscle.
If you are seeking a temporal augmentation that reaches the high temporal region to make the forehead wider as well, only a custom designed temporal-forehead implant can achieve that aesthetic change. No current implant style, Medpor or silicone, are made to create that look as a ‘catalog’ item.
Dr. Barry Eppley
Q: Dr. Eppley, I have questions about jaw angle reduction and temporal implants. Here’s a list of my questions I want to ask:
1. My jaw is still growing and i have braces, will this affect anything? What possible complications can there be? I’m willing to take all the risks and complications. ( i am getting the braces removed soon)
2. If my jaw angle is vertically reduced to make its location higher, will this make it higher from the front view too? Can this be an possible result? By higher i mean close to the ear.
3. Is there any implant to make my head larger or my forehead larger? Since my face is long, i want to make it more proportionate. I have been reading about the temporalis muscle, any implant/augmentation surgery for that
4.what is the difference between having the jaw shaved with a ear incision, and inside mouth incision? Recovery time? Results? Damage? Risks?
5. Here comes the important part… How long is the recovery time? For the ear incision & inside mouth incision? Is there any massage or laser treaments i can take to dramatically reduce the swelling so i can look ‘normal’ after a week of recovery?( i’m willing to pay a lot for any treatments that’ll help ) please include the implant part as well!
6. is it possible to do implant and jaw reduction surgery together? If so how much time will it take and what risks are there?
A: In answer to your questions:
1) Having braces and undergoing orthodontic treatment has no impact on any type of jaw angle surgery.
2) The traditional method of jaw angle reduction surgery does exactly what you are describing. It removes the jaw angle so that the most posterior part of the jaw angle is at the same level as the earlobe. It is important to understand that is so doing the jaw angle will no longer have a square form but a more rounded or sloped angulation.
3) Forehead and mid-temporal augmentation can be done to achieve a larger more pronounced forehead and increase the bitemporal distance for a wider head as judged by its width above the ears.
4) The jaw angle can be reduced by two different surgical approaches. (incisions) The intraoral method is the historic and most common method still used but it does pose challenges for angling the bone cut in an ideal and symmetric manner. The external approach uses an incision behind the ear or just below the ear and provides a much better angle for the bone cut and a quicker recovery (by staying out of the mouth) but runs the risk of causing temporary or permanent facial nerve injury. (that risk is low but is not zero)
5) There is nothing a patient can do to expedite the recovery process which is largely about who long it takes the swelling to go away before one looks human (7 to 10 days) and for its complete resolution. (4 to 6 weeks)
6) It would be common to combine any number of aesthetic craniofacial procedures such as jaw angle reduction and temporal augmentation. The risks of such surgeries, besides infection, are largely aesthetic…symmetry, over/under correction of the desired goals.
Dr. Barry Eppley
Q: Dr. Eppley, I read somewhere about temporal implants for head augmentation which I assume is of the muscle. If you add an implant there, wouldn’t it widen my head? And if so, how is it done with what type of implant and location?
A: It depends on what part of the temporal region in which the implant is placed and what type of implant is used. A preformed anterior temporal implant is now available that augments the temporal hollow. (the region between between the anterior temporal hairline and the eyebrows/side of the eye) which often occurs from aging, genetics, drug therapy or neurosurgical approaches. A larger preformed or custom mid-temporal implant is also now available that when placed below the muscle on the side of the head above the ears will increase the bitemporal dimension or width of the head. This as you can see, it is important to know what temporal region of augmentation one desires to select the right temporal implant style and location of augmentation.
Using implants for temporal augmentation is one of the newest areas of craniofacial implant development that has extended the use of implants in the face upward to that of the skull.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in temple augmentation I have a narrow forehead and narrow temporal region but the length of my forehead is fine. I was wondering if theres a procedure to widen the forehead and temporal muscle permanently as its really bothering me? I have provided an example in the photos of two celebrities, one of which has a narrow head width and the other one which is the look I desire.
A: The type of temporal augmentation you are describing can be done but it depends on how you define the side of the forehead and temporal regions. I believe by your description and the pictures that you are showing that you mean the anterior temporal regions and not really the the forehead per se. Many people confuse the anterior temporal region (non-hair bearing area between the eye and the hairline as the side of the forehead. If you look carefully at the picture of Leonardo DiCaprio you have provided you can see a very distinct line between the more convex temporal muscle and the actual bony forehead on each side. Through an incision behind the ear, a custom made implant can be placed under the anterior temporalis muscle that will build it out permanently to create that temporal/forehead wider look.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in some type of temporal plastic surgery. As you could see from my pictures my temples are not symmetrical. Even though I was born with my temporal muscles having a natural arch, an injury on the left side tore that muscle At least that’s what I hypothesis. What are your thoughts, regarding an operation that will make my skull shape even again? Thanks for your time.
A: What I am seeing is that you left temporal region is larger than your left which is most likely due to a difference in the size of the muscles in that area. This can be approached by two different types of surgeries depending upon which side of your head you like the best. If you prefer the bigger left side, then a temporal implant can be placed from behind the ear under the muscle to make it bigger. If you prefer the right side, then a temporalis muscle reduction would be needed to make that muscle smaller through a vertical incision in the temporal hairline. Or if you don’t like the bulging on either side, then the temporalis muscle could be reduced on both sides.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in temporal implants. Anatomically speaking, can you please explain to me where exactly the temporal implant will be placed- I have a vision in my mind but it may not be accurate. Will the apex of projection be between the eyes, higher up near the brow ridge, or lower beneath the eyes. Also the size of the implant, vertically speaking, how much length does it typically occupy- I imagine 5 cms or so.
A: The temporal zone can technically be divided into five regions based on the its aesthetic problems and the procedures needed to treat them. But in your case I am only going to refer to zones 1 and 2. Zone 1 (the most common area augmented when treating temporal hollowing) is between the zygomatic arch and the mid portion between the vertical distance of the zygomatic arch and the anterior temporal line. (just above the eyebrow level) Preformed implants are placed beneath the fascial covering of the muscle (not directly under the skin) to augment this area from an incision way back in the temporal hairline. Zone 2 is the area between the top portion of zone 1 and the anterior temporal line and is rarely augmented this high unless one is looking for a completely smooth transition from the forehead and the temporal region which also implies one is looking for greater convexity/fullness in the upper temporal area. Such Zone 2 augmentations can be done with large preformed implants (although they will far somewhat short of the anterior temporal line) or custom temporal implants made to fit on top of the fascia. (subcutaneous location) The vertical height of the preformed temporal implants ranges from 4 to 4.5 cms.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in temporal implant augmentation. I am a 35 year old male who ever since I was a child I have had one temple that was somewhat misshapen and sunken in. As I have gotten older and lost my baby fat, in addition to becoming leaner all around, it has become more and more noticeable and the way it looks bothers me. I see you have temporal implant treatments and I am wondering what the general ballpark amounts are for something like this. Keep in mind that only my left side is abnormal.
A: A very simple and effective solution for temporal hollowing is a temporal implant. Placed in the subfascial plane on top of the temporalis muscle, it can immediately add permanent volume to temporal hollows. For just one side, it can be placed in a 30 minute procedure under local or IV sedation. There is very little swelling and no recovery afterwards of any significance. I would have to see some pictures of your temporal hollowing to determine its extent and exact location. Temporal implants work best for when the hollowing is deepest in the temporal region just above the zygomatic arch.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 35 year-old male born with a significant facial asymmetry. I have a prominent left sided zygomatic prominence, a left ptosis and a slightly recessed left sided forehead. I also have prominent inverted-U shaped supra-orbital bossing, which divides my forehead into two, and cast unaesthetic shadows especially when I stand under light. I do understand that there are limitations to what could be corrected but I will like to explore what can be corrected. My surgical objectives would be; 1) repair of left ptosis, 2) reduction/shaving of the zygomatic prominence, 3) zygoma fossa augmentation and 4)
forehead contouring with burring/infracture of supra-orbital bossing +/- forehead augmentation. I have attached images for your review. I have also used a plastic surgery simulator to put my desire in a picture form. I would appreciate your review and consult.
A: I have taken a careful look at your pictures, including the simulations, as well as your goals and can make the following comments.
- The width of the zygomatic body/arch can be narrowed by an anterior and posterior osteotomies. (infracture method)
- The prominent brow bones could be reduced by osteotomy/infracture method. (brow bone reduction)
- #1 and #2 could be done through a coronal incisional approach. Since #2 mandates that this be used, #1 would take advantage of that approach also.
- You are showing a high temporal augmentation in the superior temporal zone. I believe you are incorrectly calling this area the zygoma fossa which I think you mean temporal fossa. This area could be augmented through the same incisional approach as #1 and #2. This would require an onlay augmentation using PMMA given the quantity of material needed as well as the size of the surface area.
- To optimally smooth out the forehead above the brow bones, some augmentation would need to be done as well above the brow bone infractured area.
- Your left upper eyelid ptosis appears to be in the 1mm to 2mm range which could be treated by an internal Mueller’s muscle resection.
- I also noticed that you have performed rhinoplasty for narrowing of your nose and lower lip reduction as well.
As you can see in the above description, the key to most of your desired changes is the need for a scalp or coronal incision to do them.
Dr. Barry Eppley
Q: Dr. Eppley, I had a craniotomy for an aneurysm over a year ago with radiation. This has left me with many effects from facial nerve paralysis. It has affected my face from the brow the whole down to the neck with a facial droop. I have attached pictures for your assessment. When I lay down my right eye does close which it did not do for quite awhile. The only movement I have on my right temple is a slight lift of the inner tip of the eyebrow. When I try to wrinkle my brow it goes slightly past center but it curves downward. The corner of my mouth was much further down than now. Originally there was no movement at all. I am now able to turn the corner up and the area of movement still seems to be increasing.
A: Thanks for sending your pictures. What they indicate to me is the following:
The frontal branch of the facial nerve is gone which is why the eyebrow does not lift up. As long as the eyebrow has not drifted lower than the opposite normal left side, I would not do any procedure for it. (i.e., browlift)
It is good news that the upper eyelid does now nearly close. As long as it closes completely when you lay down, I would not place a gold weight in the upper eyelid which is the normal treatment for a partial or slow closing upper eyelid.
The lower eyelid, as previously mentioned, needs a procedure which will help it considerably. It needs to be lifted and tightened up against the eyeball. To achieve this more is need to be done than just a traditional lateral canthoplasty. (tightening the lateral canthal tendon at the corner of the eye. That procedure needs to be combined with a fascial sling (harvested from the temporalis fascia) that would be placed from one corner of the eye to the other, much like a clothesline. Together this is the most effective method for lower eyelid tightening and resuspension.
The right face and lower corner of the mouth appears to be in some state of gradual improvement although it is probably not realistic to think that completely normal mouth movement will ever occur. However,, as long as it is improving, I may defer any type of static corner of mouth resuspension until later although that is still up for further evaluation.
The entire right facial droop may be treated with a complete facial resuspension (facelift) on the affected side. That is certainly reasonable to do at anytime. This may be combined with a corner of the mouth lift, both of which will not negatively impact any ongoing facial nerve recovery.
The right temporal area is sunken in due to the effect of the combined craniotomy and radiation, which has caused the temporalis muscle to shrink or atrophy. This is a very common effect from this exact neurosurgical procedure. The temporal area could be built back up using a variety of techniques which would depend on the dimensions of the volume lost. I can not tell exactly from the pictures to give you a better idea on how that would be done yet.
Dr. Barry Eppley
Q: Dr. Eppley, I am just enquiring about getting my head wider. I have a fairly thin head and want it wider. Is that possible?
A: When it comes to widening faces, most of the narrowing that I see is in the temporal regions from the lateral orbital wall back into the temporal muscle above and behind the ear. Augmentation of the narrowed temporal region can be done one of two ways. The first method would be to use off-the-shelf silicone temporal implants. They are designed to fill out temporal hollows and are placed under the temporalis fascia just above the muscle. While they are primarily intended to be used to fill out the temporal hollows between the side of the eye and the temporal hairline, an additional implant can also be placed above the ear level also. This does not give the ideal augmentation because of the shape of the implant, but it is the most economical approach because it uses ready-made implants. The second approach is to use custom-fabricated implants made out of either Gore-Tex (carved out blocks during surgery) or silicone (pre-made off of a skull model) materials. They would provide the most ideal augmentation because the implants cover the optimal surface area of the temporal regions.
The other narrowed area is more of the head and is in the upper temporal region back to the occiput. This is a more challenging because the temporalis fascia gets very thin the higher it goes up the skull/forehead. This makes it difficult to have a subfascial implant which helps camouflage the contours of the implant.
Dr. Barry Eppley
Q: Dr. Eppley, in your blogs about temporal augmentation have you ever come across a patient whose hollowing us deepest 6 mm to 7mms above the zygomatic arch? I ask because that is my situation. Can temporal implants correct this area adequately. Do they go down to the zygomatic arch under the fascia that far?
A: Most temporal hollowings are deepest 5 to 10mms above the zygomatic arch. They are not commonly deepest at the zygomatic arch since that is a supportive bone. Like a trampoline, the temporal hollowing is most deep away from the surrounding edges. Therefore, subfascial temporal implants will bring up these areas quite well. The implant in a subfascial location will push up the fascia right up to the upper edge of the zygomatic arch in most cases. But I have seen a few patients where the deepest indentation is right at the upper edge of the zygomatic arch. To make for a smooth transition between the arch and the temples, the implants in these cases must be placed on top of the fascia as subfascial implants can not create enough push on the strong bone fascial attachments.
Dr. Barry Eppley
Q: Dr. Eppley, In considering getting temple implants for augmentation, I have read some bad reviews about the use of silicone. I realize that these talk about their use in rhinoplasty. It was stated that silicone had a higher chance to shift and possibly become “rejected” by the body. I had read that Gore-tex enables the tissues to grow “into” it so it was less likely to switch or protrude months or years later. How does this relate to implants in the temple region. Also, I have attached an overview of the temporal augmentation procedure written by a doctor. He talks a lot about risks and complications. He makes it sound like it is a bad procedure. What do you think?
A: What potentially can happen to an implant on the nose has no correlation at all to what occurs in the temples. They are two different anatomic sites. In the nose the implant is only covered by thin skin and has potential to be exposed to the contaminated nasal airway and is, in fact, placed by being directly exposed to nasal air and the nasal linings. In the temples, the skin and fat cover is very thick and the implant is placed deep under the fascia and right up against well vascularized muscle. What can happen to an implant in these two anatomic sites is dramatically different when it comes to risk. They are not remotely comparable.
Neither Silicone nor Gore-Tex material will have tissue ingrowth. They both simply become encapsulated as they are smooth-surfaced materials.
When reading the ‘Risks of Temporal Augmentation’ summary that you sent me that was obviously written from a perspective of having never done a more contemporary method of temporal augmentation and has no craniofacial plastic surgery background/experience. It is written based on an old style way of a big coronal incision and placing some type of material under the temporalis muscle. That might be more relevant to a large temporal defect that occurs from a craniotomy but not a cosmetic temporal augmentation.
Dr. Barry Eppley
Q: Dr. Eppley, I need some type of implant to correct my severe case of temporal hollowing. I have looked at some of the available temporal implants that are available but they don’t seem thick enough to me. What type of temporal implants do you use? Do you use the silicone ones or the Medpor ones? What is the most thickness that I can get in a temporal implant?
A: Silicone temporal implants are but one type that I use. The largest commercially available temporal implant, in terms of thickness, is the silicone temporal implant. The largest silicone temporal implants measure 6cms x 4cms with 10mm thickness at one end. That would be more than adequate for the vast majority of patients. It can be quite surprising how ‘small’ an implant may look when holding it your hand and then how much change it actually makes when put in place. I have been surprised many times and have learned with many forms of facial implants that changes can be much more dramatic in place than one thinks, no matter who well one has measured and thought about the defect beforehand.
If one really needs a thicker temporal implant, it can be made through a custom fabrication process. But it is important to remember that subfascial temporal implants can only be so thick or they will be very difficult to fit into the tight space. Much thicker temporal implants need to be placed in a submuscular location which requires a more extensive scalp incisional approach.
Dr. Barry Eppley
Q: Dr. Eppley, can a temporal implant be placed on top of the temporalis facia instead of under it? Or is the risk it to become misplaced easier on top of the fascia? As the hollowing is deepest just above the zygomatic arch, so can the implants be used to correct this? And can you tell me how much this surgery costs? Many thanks.
A: A temporal implant is usually placed under the deep temporalis fascia. It can be placed on top of the deep fascia, if the aesthetic need dictates, but this does pose some potential risk for nerve injury. The frontal branch of the facial nerve is exposed to risk of injury as it courses through this area under the skin, resulting in either temporary or permanent forehead/brow paralysis. As long as one stays directly on top of the deep temporlais fascia while doing the pocket dissection, this risk is very low. Since the hollowing is usually in the middel portion of the temporal zone, that is exactly why placing a temporal implant under the fascia corrects that area the best. But in cases where the deepest indentation is right up against the zygomatic arch, placement of the implant on top of the deep fascia may be needed to fill out that area. The complete costs of temporal implants is in the range of $5500 which may vary based on what type of implant material is used.
Dr. Barry Eppley
Q: Dr. Eppley, I’m not sure what is the best procedure for me but I want permanent filling of my concave or hollowed temple areas. I have tried injectabvle fillers but none even lasted a year. I loved the look to my face that made it look more symmetrical and younger but they just didn’t last. I also had fat injections done last year but that didn’t take either and I am still concave there. It was only one fat transfer procedure so maybe it takes more than pne? I’m starting to lose hope that there’s any way to fill in the temples permanently. I feel that this issue makes me look older and definitely doesn’t help my outer droopy eyelid area. I’m unsure what my options are for a permanent fix and appreciate any direction you can provide.
A:The only real permanent fix to most cases of temporal hollowing is to place a non-resorbable temporal implant, either that of a synthetic composition (silicone) or that of a collagen matrix. (dermal graft) These are placed under the temporalis muscle fascia and are tremendously effective…and are permanent.These implants are placed through a small incision in the temporal area, have minimal swelling or discomfort, and have virtually no discomfort. This would be the best solution given that you have tried all of the injectable approaches. I do not believe that repeat fat injections will work if they did not last the first time. While temporal implants can get rid of temporal hollowing, it does not lift up or provide any improvement to a droopy eyellid area. That is outside the influence of temporal augmentation.
Dr. Barry Eppley
Q: Dr. Eppley, I have read a recent blog post of yours about an implant for the treatment of temporal hollowing with great interest. I have a depression on my left temple as a result of a craniotomy performed to clip an unruptured brain aneurysm. I would like to know more about this implant including the manufacturer, case studies of its use, and any before and after photos if available. Many thanks for your help.
A: The new temporal implant to which you refer is manufactured by Osteosymbionics in Cleveland Ohio. While it is not the first temporal implant ever designed, it is unique due to its shape and flexible design. You would have to contact the company for their clinical experience to date. I have not yet used this implant although I have used about every conceivable material for temporal augmentation and reconstruction. The material of this implant is a soft and flexible elastomer, which is what composes the vast majority of facial implants used.
For temporal defects from craniotomies, the size and extent of the depression must be carefully assessed and the implant matched to it. Some defects are due to mild to moderate atrophy of the temporalis muscle. This will appear as a more central indentation most prominent above the zygomatic arch and to the side of the forehead. An implant like this new temporal one may work well for this type of depression. Other temporal defects are bigger and are due to atrophy and a retraction of the attachments of the posterior and superior skull attachments. This creates a larger temporal depression and a bigger implant or other form of temporal reconstruction must be used.
Q: Hi, After I was born, a hematoma appeared on the back top right corner of my skull (either trauma on the way out of my mom, or trauma suffered after being born…we’re not sure.). It ended up calcifying after being left untreated (at least that’s what doctors have said in the past), and to this day, the lump is still there. It’s about 1.5 inches in diameter and sticks up about 1/2 inch from my skull. This wasn’t necessarily a problem growing up, because hair could cover it up. But unfortunately, genetics have brought on the beginning stages of male pattern baldness. I’m thinning quickly, and a hair transplant seems unlikely at my age of just 23. Therefore, I would like to get used to shaving my hair down, but as we all know, people need a good head shape to pull it off properly. Another side note, but not necessarily as important: I have a prominent forehead that sticks out a bit further than the ridge of my browbone, and my temples are a bit hollowed out. I wear bangs to cover this stuff up as well, but with hair loss, this isn’t feasible in the long run. I’m not sure if these things are fixable, but hopefully I can begin to get some information on what should be done. This stuff is killing my self esteem! I’m a good lookin’ guy! I’m in college! This shouldn’t be happening right now! Looking forward to your response.
A: What you had an birth was a cephalohematoma, a blood collection under the skin and more pertinently under the periosteum of the bone. This is a well known stimulant to bone formation and they are well know to calcify. It can certainly be rather easily burred down which is a simple procedure. The key is to be able to do it with a fairly minimal resultant scar. (incisional access) Given its relatively small size, that should be able to be done with a very minimal scar of about an inch placed vertically on the back of the head at its lower end.
The forehead issues can be similarly treated through burring reduction but the problem is one of hidden surgical access. In the forehead with an unstable hair pattern in a male this is not very feasible. A long scar placed across the top of the head is not a good trade-off. Having a smoother and less bulgy forehead at the expense of a long scalp scar may not be a good aesthetic alternative.
Your temporal hollowing, however, can rather easily be improved through a temporal augmentation procedure. Dermal grafts can be placed under the muscle fascia through small vertical incisions in the temporal scalp. Rounding out the temporal area will help blend in with the forehead shape better.
Q: I would like to ask if you do use fillers for augmentation in the temple zone, where I have sufffered fat loss. If it is possible, what filers would you use? I look forward to hearing from you.
A: Temporal hollowing is a result of fat loss which occurs for a variety of reasons. Some people have it at birth, some develop it with aging, and others develop it from certain medications and surgical procedures. Either way, it is a deflation of the temporal muscle as the fat is lost underneath and around it. While synthetic injectable fillers can be used to fill it, it is not my first preference. This is because it takes a lot of filler to augment the area and, given that they are not permanent, is not a good value in the long run.
My choices would be either injectable fat, a synthetic implant, or a dermal graft implant. Any of these are surgically placed beneath the deep temporal fascia on top of or underneath the muscle. I have used them all and find that for most cosmetic augmentations (not caused by a craniotomy or temporal muscle detachment) the use of a subfascial dermal graft woks well. It is simple to do, is a natural collagen material that is soft and flexible, and appears to have good long-term retention. Some would argue that fat injections are best, and I do like them, but their volume retention is not as assured. Through a very small vertical temporal incision, sheets of dermal graft can be placed which fill out the hollowing very nicely.
Dr. Barry Eppley
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.