Q: Dr. Eppley, I am interested in temporal implants. I wanted to know if you have picture of the scar like one year after surgery? Or just a picture of the scar, to know what it will look like. I like to keep my hair shorts, and I wonder what it will look like? As a second question, would therapy to heal scar would help making it less visible?Also, as a third question, what would be the shortest I can keep my hair on the side to hide the scar? 0.5 cm or more? Thanks.
A: I do not have a picture of a temporal scar after implant surgery. I have seen several of them long-term and many of them are virtually undetectable even on very close inspection. I can also say I have never been asked to do a scar revision on the scars after temporal implants. If one has hair there would be no need to do any form of topical scar therapy on the incisions. This is impractical and unnecessary for scalp scars. If the temporal hairline scar heals very well (and it should) you should he able to wear your hair as short as you would like without concerns about visible scars.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in facial reshaping surgery. I would like to make a great change on my odd facial appearance. I would like to have a facial reshaping on my interpupillary distance (IPD) and innerouterintercanthal distance (IOICD) because I think I got hypertelorism. I have 4.5cm telecanthus, 3.6cm intercanthal distance, 3cm orbit, 7.5cm interpupillary distance (IPD), around 14.5-15 cm facial width and around 19.5 cm facial length. What surgery should I do at this stage? Decrease interpupillary distance (IPD) by Facial bipartition or increase bitemporal distance and by custom implants? Thanks for your time. I am looking forward to your reply!
A: Thank you for inquiry and sending your pictures. For your facial concerns no major craniofacial surgery such as a hypertelorism or facial bipartition repairs would be appropriate. These are major intracranial surgeries with some significant risks that would not be justified for a cosmetic issue such as type 1 hypertelorism or mild increased intercanthal distances. Instead you want to think of other smaller facial reshaping procedures that can help improve that appearance. You have a low nasal bridge and epicanthal folds. Reducing the epicanthal fold appearance and augmenting the height of the nasal bridge (augmentation rhinoplasty) are well known manuevers that will help make the eyes looks somewhat closer. Making the adjoining areas wider (temporal augmentation) is another option to consider also. When you put all three of these facial procedures together they will do a lot to decrease your perception of the eyes being too far apart.
Dr. Barry Eppley
Q: Dr. Eppley, I practice plastic surgery in Chicago. I attended a cadaver course on facial implants last year in Las Vegas where you gave a superb number of lectures on a variety of facial implant procedures. I have a question regarding temporal implants and which tissue plane to place it in, I can not remember exactly what you said. From what I remember, it was placed under the superficial layer of the deep temporal fascia (on the temporalis muscle). Is that correct? Also, what would be the reason to not place it on the fascia? Thank you for your time.
A: Temporal implants should always be placed in the subfascial tissue location. (under the deep temporal fascia and on top of the temporalis muscle. Temporal implants should NEVER be placed above the fascia. Placing temporal implants in this area is what has caused them to be described as a bad procedure due to complications. When temporal implants are placed above the fascia the outline of the implant will be seen when the swelling goes down…not to mention the potential risk of injury to the frontal branch of the facial nerve in placing it in this more superficial tissue plane.
Dr. Barry Eppley
Q: Dr. Eppley, I hope this email finds you well. I have always been self conscious of my small head and weak Jaw. I recently had custom jaw and chin implants placed 7 months ago. I am happy with the results, especially with the chin, but would like to go with something bigger at the jaw with more support at the side between the jaw and chin. I assume I would need an inferior drop to the jaw, where my prior implants had none. I wanted to know how feasible this is to do from a safety standpoint and how the recovery would be compared to the original?
Regarding my forehead, it narrows inward and is concave compared to my zygomatic arch. I saw that you perform temporal implants with amazing results. I just wanted to know if these implants will feel natural once they are placed?
Finally, what kind of costs am I looking at for these procedures? I would want custom implants again for the chin/jaw but I don’t know what you would recommend for the temporal area. I would of course defer to you for both decisions. Finally, how much would these procedures cost in total if done together versus done staged?
A: Thank you for your inquiry. I would need to see pictures of you to give specific answers but I can provide the following general comments.
Since you have indwelling jaw angle implants in place that do not appear to provide any vertical elongation, new jaw angles can be placed. It helps that you have existing pocket so, in theory, the swelling and recovery would be less. (I assume your custom implants are made of silicone. Releasing the implant pocket and dropping the jaw angles down further is not a safety concern.
Based on your description of your temporal deficiency, it sounds like it goes all the way up to the forehead. Thus what you need would be what I call extended and Zone 1 and 2 temporal implants. All such temporal implants are placed on top of the muscle but under the fascia. Patients do not report any problems with such temporal implants feeling unnatural.
As for cost I am a but unclear as to how your current chin and jaw implants were made when you say custom. I assume this was done off of a 3D CT scan. If so that same scan can be used again. I will have my assistant Camille pass along the cost of the procedures if done together during the same surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I briefly exchanged messages with you a couple of years back as I was quite distressed with certain aspects of my appearance, namely the extreme narrowness of my skull and length of my face. I tend to have a narrower skull/face than most, male or female. I have a very dolichocephalic skull, with all the usual signs; long midface, excessive occiput, narrow bitemporal area etc. I had a mild skull deformity and borderline long-face syndrome that caused vertical facial growth and heavy asymmetry of the face. I have subsequently had surgery with jaw angle implants and a genioplasty. I am very happy with the results as it has gone some way to adding width to my face and restoring an element of balance. However, I have been very impressed with your extensive information on the possibility of forehead/anterior temple widening. Or basically, overall widening of the face and skull. I think that could apply to my situation where I want to add masculinity and width to my face/head. I have attached some before and after pictures for you to hopefully take a look at. I have tried to find pictures that show similar camera angles in the before and afters.
The questions that I have are:
– Can you see potential for my forehead and temple area to be widened?
– I have always had a small mouth, but since having the jaw implants it has perhaps become a bit more apparent. Can anything be done to widen the lips?
– I believe that the surgery I have had has helped to balance my midface somewhat, but still think it is perhaps a bit too long. Can anything be done to shorten/balance the midface?
Thank you for taking the time to read this. As a potential foreign patient, naturally I have many questions to ask before hopefully flying over! Have a good day!
A: As I suspected back then shortening the chin and adding facial width by jaw angle implants will go a long way to make your face less long and a bit wider. Adding extended temporal implants that go all the way up to the side of the forehead as well as posterior temporal implants will add further benefit to this overall effect.
While you can widen the lips at the corners of the mouth, there would be small scars to do so.
There is nothing you can do to shorten the midface. That is a fixed structure that can not be changed without burying the upper teeth under the upper lip.
Dr. Barry Eppley
Dr. Eppley, I am looking for temporal implants due to significant thinning of my face with age and weight loss. I would also be interested in possible fat transfer or other procedures to fill my cheeks in some. Would like to consult on what my options are. Here is one old photo of me 30 years ago, I don’t ever expect to look that young again, but I would like my face to be plump or full looking again like it used to be. I’ve lost a lot of weight and my face now looks sunken and sickly. Please help me. I am embarrassed by my appearance.
A: Thank you for sending your pictures. You have very classic panfacial soft tissue volume loss which is very common in significant weight loss particularly in an older person. It affects some individuals more so than others. This is most manifest in your temporal region where it has turned into a complete concavity from the zygomatic arch all the way up to the anterior temporal line on the forehead. It is seen less severely in the cheek area only because your naturally high cheek bones have preserved some of the volume. (there is no bone protecting the temple areas) For your temporal areas there is no question that an extended temporal implant is the preferred procedure as it will create a permanent volume solution to that problem. It requires an extended temporal implant as opposed to the standard one given that it needs to reach all the way up to the forehead. For the cheeks your options are submalar cheek implants or fat injections. Each one has their own merits. (fat is better at total area volume addition but its survival may not do well given your age and lack of natural fat in the area…an implant has assured permanent volume but only provides volume to one specific area) In facial volume lose cases like yours I will often combine submalar cheek implants with fat injections to get the best of what each has to offer.
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 am interested in temporal augmentation. My questions are: 1) I would prefer to try filler first, with filler is it possible to do the whole region which I circled in red in my picture? From the implant I saw from your site, that goes really higher than the smaller ones (see the second picture). I’d like to cover all this zone with hyaluronic filler.
2-) I wonder since I have a flat upper head appearance from the front view, if I can create the effect of the guy I circled in green? His hair don’t seem to be flat on his side of the head. not sure if it’s clear. I’d like to have this volume to my head. (circled in red)
A: When it comes to temporal augmentation it is all about volume and what it costs to do it. You can certainly use injectable fillers but it will be really expensive to build up the whole temporal region (non-hair bearing and hair areas) for a six month result. The only reason to consider such a temporary treatment would be to first see if you like the augmentation effect by ‘wearing’ it for awhile. The use of anterior and posterior temporal implants, which are permanent, are a more cost effective long-term approach.
Dr. Barry Eppley
Q: Dr. Eppley, I have questions about temporal augmentation. I just got cheek implants and am modestly happy with them. I wanted to know if temple implants can co-exist with cheek implant. My surgeon has explained to me that temple implants are not safe due to a sensitive nerve in that area, and something he does not practice, nor advises.
A: I am afraid to say that what your surgeon is telling is inaccurate and anatomically incorrect about temporal augmentation. Temporal implants are placed in a subfascial pocket through a small incision in the temporal hairline. There are no nerves in the subfascial temporal plane which is directly on top of the temporalis muscle. Your surgeon is likely referring to the subcutaneous temporal location where the frontal branch of the facial nerve runs. The subfascial is below that location and is perfectly safe.
Cheek and temporal implants can co-exist because they are in completely different tissue pockets even though they are right next to each other. Cheek implants can make the temporal region above it look hollow/deficient and it is not rare in my experience that the cheek implant patient subsequently goes on to have temporal implants.
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, Would temporal implants cause any facial muscles movments difficulty? For example, it wouldn’t look natural when doing facial expression?
A: Temporal implants are placed in a subfascial position over the temporalis muscle. The temporalis is a muscle of mastication (chewing) not of facial expression. It can not affect any aspect of how the face moves in making any form of facial expression. The temporalis muscle is attached to the lower jaw and it major responsibility is in elevating or closing the lower jaw. But since the immplant sits on top of the muscle (but under its fascia) it causes no interference with jaw movement or jaw closing either.
Temporal implants are designed to be add visible volume to the temporalis muscle in the area above the zygomatic arch and to the side of the eye. It is maintained in its subfascial location by being bigger than the circumference of the space inside the zygomatic arch and the bony coronoid process beneath it. Because the implant is smooth the temporalis muscle glides smoothly under it without interference or scar contracture. Its add permanent volume which makes it superior to temporary fillers and fat injections.
Dr. Barry Eppley
Q: Dr. Eppley, Do you do temporal implants for people after craniectomy/craniotomy? Or only for those with wasting from other nonsurgical issues. I had a craniectomy after brain surgery after fractured my skull in a car wreck. Despite the severity of the injury I have made a full neurologic recovery.
However the neurosurgery itself caused a massive amount of temporal hollowing. My neurosurgeon for the last year has said I’d be eligible for 3D custom implants. However after waiting a year and consulting with another doctor who is supposed to specialize in 3D custom implants he told me he had only donetwo temporal implants which both had to be removed and would not do them on me. I’m not sure if there was a further scientific based reason for this as my appointment with him only lasted five minutes. He also said he would not recommend me to get the implants done by anyone else.
I understand these 3D custom implants have been around only shortly since 2013 but I know regular temporal implants have been around for decades. I feel trapped in being disfigured like this and don’t know where to really look for a solution. I’m not sure why my neurosurgeon would recommend me for 3D custom implants for a year and then I’d not be eligible for them or for any cosmetic solution to my temporal hollowing.
Do you take patients from Canada? I would really be relieved to find a solution to this as Canada does not have many plastic surgeons in total and then even fewer that have dealt with cranioplasty let alone anything with soft tissue replacement implants.
A: I have done temporal implants for years for both aesthetic purposes as well as for reconstruction after neurosurgery due to temporal muscle wasting/detachment. The key factor in success in neurosurgery patients is whether they have had radiation to the temporal region or not. With your trauma history, you clearly have not received temporal irradiation. I can not give you a good reason why two separate surgeons would not do a 3D temporal reconstruction on you. Unless there is something that is not clear to me, I can not envision the circumstances where it is not possible. Can you send me some pictures of your temporal deformity and any CT scans that have been done since your surgery. I know the CT scans may or may be available and are not important right now. If based on your pictures I feel you are a good candidate then we would need a new 3D CT scan anyway.
The success of any craniofacial implant reconstruction is the quality of the overlying soft tissue cover. Adequate thickness and good vascularity of the tissues are important for long term success.
I have patients that come from all over the world and Canadian patients, because of proximity to the U.S., are some of the most common international patients I treat.
Dr. Barry Eppley
Q: Dr. Eppley, Im very interesed in the temporal implant/augmentation for a more youthful look.I have atrophy from weight loss and aging over the years.I also feel that there is some geneic predisposition for me to have this,as well.I no longer wear my hair pulled back because it accentuates the problem. I have a very busy business and am curious how much downtime this procedure requires? Also, how effective are they and can they be removed in the future?
1) There is very minimal downtown from temporal implants. You could return to your work within 48 hours with only minimal temporal swelling.
2) Temporal implants are the most effective treatment that I know for temporal hollowing. The surgery is short, down time minimal and the volume results stable and permanent.
3) Temporal implants can be reversed just as easy as they are to put in.
Dr. Barry Eppley
Q: Dr. Eppley, Here are some questions I have about head widening surgery with temporal implants. I am very interested in this procedure but just want t make sure I have all of my bases covered being having it.
1) When having the implants in the head, are the visible in airport X-Ray and scanning machines, it would be quite embarrassing to have them visible in the machines?
2) Are they comfortable to have in the head?
3) Is there some other alternatives than having the implants.
I would appreciate your help in answering my questions. I really have a big head shape problem in the width and I want to change this permanently.
A: In answer to your specific questions about head widening surgery through temporal implants:
1) Silicone implants can not be detected by x-rays or airport scanners.
2) Submuscular temporal implants feel very comfortable and natural and patients do not report any abnormal feelings from having them in place.
3) An alternative to implants for head widening surgery would be fat injections with PRP. (platelet rich plasma)
Heading widening surgery done with submuscular temporal implants is a very effective procedure that is accomplished in a scar-fee scalp technique through post auricular incisions.
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 recently spoke to you regarding jaw implants. I am still in the process of getting custom jaw implants done, however, I’ve decided with my surgery I would also like to get temporal implants. I read your notes (very helpful) on this surgery and I want to know if temporal implants for men will achieve a square top half of the head… similar to how jaw implants make the bottom half of the face more square. After having jaw and cheek implants I’ve noticed that my temples look sunken in and my face doesn’t look normal when my hair is brushed back. I guess Im wanting to know that the goals I’m wanting are achievable with this implant. I also find that I can’t wear short male hair styles that can make the face look square and masculine because my temples sink in a bit.
A: The answer to your question is all in how the implants are designed and at what tissue level they are placed. Traditional preformed temporal implants go into the hollows between the hairline and the eyes under the fascia and on top of the muscle. I get the impression that your temporal concerns are more towards the mid-temporal area back in the hairline and upwards toward the top of the head where it transitions into the horizontal skull plane. Augmentation of this area requires custom implants that need to be placed above the fascia in the ear area that extends upward to the temporal line to create that effect.
I would, however, really need to see some pictures of your temporal concerns to provide a more qualified answer.
Dr. Barry Eppley
Q: Dr. Eppley, I am considering having a cranioplasty and/or temporal shell implant. I recently had a cranial CT done, and was wondering if you would be able to recreate that into a 3D CT scan in order to make the temporal shell implant, or at least to get a better idea of which areas are deficient in the cranium in order to better place the PMMA cement. Could you please let me know the costs associated with translating the CT scan into a 3D format, and if this would help you even with a PMMA cranioplasty without temporal shell implant?
A: Unless the original CT was taken in high resolution cuts (1mm or less), you can not get it converted into 3D CT images.
When it comes to what you are calling a temporal shell implant, I need to know exactly the temporal area to which you refer in terms of augmenting. There is skin only area between the temporal hairline and the eye which is where preformed temporal shell implants are used to augment. I am going to assume this is the temporal area to which you refer. A regular or 3D CT scan is not helpful in addressing the volume needs of this area since this is a muscular augmentation area and not bone. A CT scan, particularly a 3D one, only shows bone.
The only reason to get a 3D CT scan for the forehead is if one is getting a custom temporal implant made. If one is using PMMA bone cement, the scan is not really helpful as this is artistically applied and shaped during surgery.
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 a middle-aged man who have been considering elective surgery for a long time. Due to my temple hollowness, I have had injectables (Radiesse, Sculptra, fat) in the area for long time, but with very limited effect and minimum duration. I am looking now into a more permanent solution, like temporal implants. On the other hand, due to my “sad look” a lateral brow lift has been offered to me several times, however, do you think that correcting the temples could fill up the area around the orbital contour or a lateral brow lift could still be needed? If so can both procedures be done together? My separate question to you is to whether a facelift could be performed at the same time as the one or the two procedures discussed above. Thank you in advance for your reply.
A: Temporal implants would be the only effective treatment option with your type of temporal hollowing. Your thin facial tissues have little fat and this explains why any type of injectable filler, including fat, can persist. Subfascial temporal implants will provide a permanent result by muscle augmentation. Temporal implants will not lift up the tail of your brows, n matter the size. That will require a temporal browlift, best done in men through a transpalpebral approach using an endotine fixation device. A facelift can certainly be done at the same time with careful placement of the incisions around the ears.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in temporal implants but I have a twist to my need. I am bald and can’t regrow hair so I keep my head shaved. In addition I had a direct browlift last year so there are healed incisions right above my eyebrows. My question is can these implants be placed by going through the brow incisions? I hate that I would need temporal scalp incisions which would be very visible in someone like me.
A: While temporal implants may be aesthetically beneficial for you the question is how to get them in there in a ‘scarless’ manner in someone who shaves their head. This is a unique male question and not one that is seen in females. As you have read, the approach for temporal implants is from a 3 to 4cm incision just above the ear. While that approach makes it very easy and simple to do, the concept of a fine line scar in shaven scalp skin does give me pause. Your question of whether a temporal implant can be placed through a direct brow lift incision is an interesting one and the presence of a scar in that area poses a unique ‘opportunity’. The eyebrow incision for temporal implants is one I have never done and I doubt if it has ever been done anywhere in the world to date. By its proximity your eyebrow scars provide direct access to the area of temporal hollowing but the attachment of the temporal fascia to the lateral orbital bone is quite stout and would have to be released to gain entrance to the subfascial temporal plane. (having done a lot of craniofacial surgery I am very familiar with doing surgery in this area) The simple answer to your question is that it is theoretically possible and if one was doing some adjustment of your direct brow lift anyway there is no reason not to try. If it becomes too difficult to do, one can always then switch to doing fat injection into the muscle and on top of the fascia to create a temporal augmentation effect.
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 have a question about temple implants. What I want is to build width and length to my face through multiple procedures. (Not all done at the same time of course). These include jaw implants to add width and vertical length to the face, a chin implant which meets the jaw implant, and forehead widening from the temporal region up into the sides of the head, and possibly heightening. I believe the chin and jaw implants are relatively straightforward, but the forehead is a bit more complicated to me. Is the recovery period painful for skull reshaping and is there a significant loss of blood? One question I’d like to ask is how much width can be added to the forehead on each side? Is it possible to broaden the forehead up to 1cm on each side stretching from the cheekbone all the way up to the highest part of the head? As you can tell I really want to completely restructure my face to more large proportions and just add volume all over as it has bothering me greatly for some time now. I do not want to do anything with my features as I like my features, its the size of my structure that I really want to change.
A: When it comes to temple implants, there are two major factors to consider in your specific request. First, the amount of temporal and forehead augmentation is only limited by the ability of the scalp to close over it. Based on a lot of experience in these kind of surgeries I would say that a 1 cm increase on each side is very achieveable. Secondly, it will require custom designed temporal implants that would be made to start at the zygomatic arch and create a maximal 1 cm width increase at the point of maximal convexity as it blends into the forehead area. I have designed such temporal implants in the past so this amount of temporal volume addition I have done before.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in some facial reshaping procedures. I am 54 and desire more of a heart shape to my face. It is long and not as feminine as I would like. My nose is a bit long and wide on the bridge (from the front esp.) Looking younger would be great, but looking more feminine and therefore prettier is my main goal. Wider temple area/distinct cheekbones, tighter jaw to neck angle, more of a right angle beneath chin-to-neck, and a feminine nose are some ideas I have. My jawbone has reabsorbed somewhat, according to my dentist. But I need YOUR trained eye to tell me how to accomplish my goal of looking more feminine, losing the chub underneath my chin, creating a prettier facial shape in general. Thanks so much for giving me the straight scoop.
A: In looking at your pictures and understanding your facial reshaping goals, I would recommend the following changes.
CHIN A V or triangular shaped chin implant augmentation with the objective or bringing your chin forward, which is short, but making it narrower at the same time.
NOSE An open rhinoplasty to narrow the nose from the bridge to the tip with some slight shortening and elevation of the tip with nostril narrowing.
CHEEKS Cheek implants that produce some a combined malar/submalar (shell) effect. This with the chin helps create more of a heart-shaped face.
TEMPLES Subfascial temporal implant to correct the hollowing and increase the bitemporal width.
EARLOBES I know you did not mention these but these seem a little bit and stick out and reducing them adds a touch of femininity to the sides of the face.
I have attached some computer imaging predictions of how I see these changes affecting your face.
Dr. Barry Eppley
Q: Dr. Eppley, Thank you for your information on temporal implants. I live in Los Angeles, and I have been getting fillers injected into my depressed temples for a couple year with limited and very short lived results. My hollow temples are genetic and non trauma related. I understand from your site that you perform a silicone temple implant procedure. I am however in Los Angeles, and wonder if you could recommend a surgeon here or in the Beverly Hills area who may also perform this procedure. Thank you for your help.
A: By your description of the temporal hollowing and lack of any sustaned results from the use of injectable fillers, you appear to be a good candidate for a permanent solution using subfascial placement of silicone temporal implants. Unfortunately due to the relative newness of the commercial availability of the the temporal implants, I am not in a position to know whom in Los Angeles or even California has yet performed this procedure.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 25 year old male and I am interested in facial cosmetic surgery. My previous history of cosmetic surgery is otoplasty, rhinoplasty and a chin implant. I would like a more balanced face and more of an oval/square shape.
-Is it possible to augment more on the weaker side (jaw and cheeks) to balance asymmetry?
-On the cheekbone I would like to augment both the temporal process and the zygomatic bone, augmenting both the sides and front of the cheek bone (particular more augmentation on the right side to balance the weakness)
-On the mandible, i would like the Ramus more laterally augmented (a more square jaw) (also particularly more augmentation to balance the weakness on the right side)
-On the nose, a narrower and more defined tip
Left and right profile views:
-augmentation of the cheekbone (both the temporal process and the zygomatic bone)
-more square mandible angle
-slight de-projection of the nasal tip, lower and upper cartilage*
*Tip projection is more pronounced in the photos of the oblique smiling views.
I am sending pictures of anterior view and right oblique smiling view. If you could please send me altered photos with your expected results explaining the procedures you have added and why you feel so.
Thank you for your time and consideration
A: Thank you for your inquiry. Unfortunately the images you have sent me are inadequate for imaging. Only the front view is useful. A NON-SMILING oblique and side views are needed to get a more complete analysis.
1) It is not clear if the images are flipped or not. As I see them, the left side of your face is the smaller or weaker side.
2) The concept of oval and a square face are contradictory. As a male I will assume you mean more of a square facial shape is what you desire.
3) While the temporal hollows can be augmented, the bony zygomatic arch and its temporal process which lies below it can not.
4) Correction of facial asymmetries is difficult even using differently sized implants for each side. Improvement may be obtained but do not expect perfect symmetry as that will not happen.
5) Since you have already have a rhinoplasty, what was done to the tip of the nose initially? What tip changes ere already done and didn’t achieve your goals? It is now a scarred tip and a review of the previous operative note would be helpful to know what now lies underneath and whether cartilage grafts were harvested from your septum. You also have a right middle vault collapse, a step-off at the osteocartilaginous junction, significant nasal deviation and nostril retraction/asymmetry. These and the desire for tip de-projection are going to require cartilage grafts.
All this being said, I have done some imaging based on the one useful frontal view that you have provided with jaw angle, cheek and temporal implants as well as revisional rhinoplasty.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in forehead augmentation to improve my sloping forehead above my eyebrows. I can see how that would improve the shape of my forehead in the profile view but I am curious what will happen in the frontal view. I have attached a front picture of me and marked with arrows the area of my forehead that I see as too narrow.
A: You bring up a very critical point in your forehead concerns. The area to which you have shown the areas is not the bony forehead. That is the soft tissue temple area. That would be unaffected by a bony forehead augmentation and may well look somewhat more narrow as the bony forehead comes forward. (probably won’t change it very much if at all) To improve temporal fullness or width, that requires a temporal shell implant placed on top of the muscle to build up that area. (make it wider) It is common to not be aware that the width of the bony forehead stops at the anterior temporal line that runs above the corner of the eye back into the scalp. This is where building up the bony forehead stops. Beyond that line to the sides the contour is controlled by the temporalis muscle and deep fat pad.
Dr. Barry Eppley
Q: Dr. Eppley, I suffer from sever temporal wasting. It’s rather noticeable. I’ve heard fillers are recommended but are they for minor filling and not severe cases of hollowing of the temples? Can they really fill my temples?
A: While injectable fillers or fat can be very good for more minor or moderate cases of temporal wasting, they have limitations in deeper temporal depressions. When it comes to more severe wasting of the temporal regions, fillers do not do a good job of augmentation as they take a fair amount of volume (high cost) and are temporary anyway. Fat injections are often a problem in severe temporal wasting as the patients may have little fat to harvest on the rest of their body. There is also the issue of what caused the fat wasting in the first place which can work against any transplanted fat survival.
Synthetic mplants as part of a more complete treatment strategy for temporal wasting can be more effective and also are permanent. Different-sized temporal implants are available to fulfill various volumetric needs.
Q: Dr. Eppley, do you think temporal implants is gonna have a positive change to my face? I want my upper face be wider than the lower part but I don’t want it to look fake or obvious. Lastly, can the temporal implants be fixed permanently so there is no risk of displacement?
A: I would have no concerns with temporal implants about looking fake or being too big. Conversely the issue is actually whether they do enough and satisfy your aesthetic desires. The implants are placed in pockets beneath the temporalis fascia so there is no need for fixation to prevent displacement as there is nowhere for them to go. They can not get outside of the pockets that are made to receive them.
Dr. Barry Eppley
Q: Dr. Eppley, I have narrow forehead and temporal area and I have wide jaw line. I want to get a wider upper face to equalize my wide lower face. Can temporal implants help me? Because of my deep set eyes, I am concerned that any such widening may make them look even deeper.
A: Based on the picture you sent, I can see the aesthetic value of temporal implants in terms of improving your desire for upper facial widening. Based on the size of the temporal implant, your temporal region can have varying degrees of increased convexity. I do not see how any widening in the temporal area will have any effect on the appearance of your eyes as they do not affect the prominent of the lateral orbital rim, one of the circumferential bones around the eye. As long as you do not increase the brow prominence, you will not deepen the eye area.
Dr. Barry Eppley