Q: I’m writing to you from after reading your article on temporal hollowing. I’ve been trying to find a recommendation on how to treat the temporal hollowing on the left side of my face that developed several years ago. I have yet to be satisfied that any surgeon I have seen truly understands the problem and how to treat it. Those that have seen it recommended some form of fat injection to mask it. Most of the surgeons wouldn’t speculate what might have happened that caused the hollowing, but I recently found out what it was. One surgeon asked for a CT scan and it was quite obvious that the temporalis muscle and the fat pad behind it was sitting around 1 inch lower, at the temple, on the left side than the right. In addition, the collapsed fat was bunching up behind the zygomatic arch causing the soft tissue to bulge above the zygomatic arch.
Several years ago, I was involved in a cycling accident that left me with facial fractures on the left. One bicoronal scalp incision and multple plates and screws later I was quite well put back together. Within a year though, I had developed a droop in my brow, one of the plates was loose along my left orbit and I had developed a minor protrusion on the zygomatic arch. The surgeon I saw opened the bicoronal scar up, lifted the brow a bit, remove the loose plate and burred the left zygomatic arch a bit. When I saw him a month later with hollowing in the temporal fascia, he had no idea what might have caused it.
You’re the first surgeon anywhere in the world that I’ve found who has experience in treating this problem. As you’ve mentioned that different filler materials may be used depending on the case, I’d be really interested from hearing from you about what you believe to be the best treatment in my case. Also I am interested in reducing the bulge over the zygomatic arch. To date, only the surgeon has made any recommendation in that regard. He suggested that a small amount of Lipodissolve might be used along the top of the arch in order to reduce the fat along it prior to applying the filler treatment. The same doctor suggested Aquamid as the filler, but after researching this, I have decided against it as there are a large number of reports on the Internet referring to negative side effects.
A: Thank you for sending me your photos and providing your history. I think it is quite clear as to what the origin of the temporal hollowing is. In your first bicoronal craniofacial fracture repair, little or no temporalis muscle was lifted up to do the primary fracture fixation. But in the second procedure, the zygomatic arch was burred down. The only way to safely approach the zygomatic arch to do any burring, without risking injury to the frontal branch of the facial nerve, would be to do some elevation of the temporalis fascia near the zygomatic arch and come at it from underneath the fascia. With this approach, some temporalis atrophy (aka temporal hollowing) can be one of the side effects to doing so. Your temporal hollowing is not major compared to many other patients, but it is noticeable.
The correction of your temporal hollowing could be done by subfascial implant placement. While there are a variety of materials to use, I would place a allogeneic dermal graft if it was an isolated procedure. However, that approach MAY change if you are trying to get the arch prominence reduced. I do not think (until proven otherwise) that the prominent area over the zygomatic arch is fat. More likely, it is bowing of the zygomatic arch bone. Fat does not cause that bulge unless the zygomatic arch is no longer present. If it is indeed the arch, burring will not work for it. The bone is too thin. A more effective approach would be to osteotomize the arch’s front and posterior attachments and let the entire arch complex settle in a bit. This is a modification of a technique that I use for cheekbone reduction.
The combination of temporal augmentation and arch reduction should get you close to your intended aesthetic temporal/cheek goals.
Dr. Barry Eppley