Your Questions
Your Questions
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?
A: Thank you for your inquiry. You may well be correct that temporal widening alone using temporal implants or combined with forehead widening may be beneficial for better facial balance. I would need to see some pictures of your face to make a more definitive determination. I will also be interested in seeing the frontal picture of you to see how wide the cheeks are also. It is really a question of whether the location of the temporal expansion can create enough of an effect to make a visible difference in upper facial width.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I would like to have temporal augmentation on both sides. I want a permanent solution which means no fat injections. I don’t want to have to do it every few years. I am ok with silicone implants. Because there are nerves in temporal area is temporal augmentation safe? I am scared of getting my nerves hurt. Can you please tell me what are the possible options for the implants.
A: The use of preformed synthetic implants is the only assured method of permanent temporal augmentation. There are several different designs from two manufacturers today. These implants are most commonly placed below the temporalis fascia on top of the muscle. The frontal branch of the facial nerve which runs through the temporal area lies above the deep temporal fascia, thus subfascial temporal implant placement poses no danger to this nerve which is responsible for movement of the forehead and eyebrow. There are some cases in severe temporal hollowing with a tight fascial lining in which the implants are better placed above the fascia to get the desired augmentation effect. This is usually necessary when there is a large step-off between the zygomatic arch and the temples. When above the fascia, it is important to place it right up against the deep fascia and avoid dissection in the more superficial fascial layers where the nerve runs. When done properly, temporal implants placed above the fascia are safe.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have read and is interested in your procedures concerning temporal implants, I have read that if placed on top the fascia the temporal branch that moves the forehead can be damaged, now I know there is also another nerve in that area which controls the upper eyelid muscles, so can this nerve also be injured if the implant is placed on top the deep fascia?
A: You are correct in assuming that the frontal branch of the facial nerve has the potential to be injured with placement of an implant on top of the deep temporal fascia. This small singular nerve branch is known to course through the tissue layer just above the deep temporalis fascia. While that tissue is easily raised off of the deep temporalis fascia, it can still be potentially injured during this dissection or even from the pressure of an implant beneath it. With frontal branch nerve injury, movement of the forehead (frontalis muscle) will be affected. If this nerve should be injured, recovery may or may not occur as this nerve branch has no cross-innervation from other nerve branches. For this reason, I generally place temporal implants deep to the fascia. But in some cases to get the desired aesthetic result, the implant must be placed on top of the deep fascia. and the potential risk of nerve injury must be accepted.
Frontal branch nerve injury, as might occur with a temporal implant placed above the deep temporal fascia, does not usually affect the eyelids. Sensory innervation of the eyelids is through terminal branches of the ophthalmic nerve (cranial nerve 1) and maxillary divisions of the trigeminal nerve. (cranial nerve 5) The levator palpebra superioris (upper eyelid levator nuscle) is innervated by the superior branch of the oculomotor nerve. (cranial nerve 3) This is why when one looks upward, the eyelid moves upward as well.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have what I would consider a significant amount of lipoatrophy in my face (and I’m HIV positive for almost 4 years). I also unfortunately had a small amount of buccal fat removed when I was younger. That, combined with the lipoatrophy, has left my cheeks, buccal, and temporal areas looking quite thin (and in my view, gaunt). What do you feel is the best way of treating this fat loss? I’m not really interested in an implant due to cost and I really am interested in restoring volume. I have had Sculptra treatments previously, but the results were not long lasting and did not restore an adequate amount of volume in my view. I have considered facial fat grafting, but am concerned about the reliability of whether that fat would survive (especially in someone with HIV). I am interested in your thoughts as to what the best course of treatment may be for something that is not short lasting and not outrageously expensive.
A: The only reliable permanent method of restoring volume in the malar, submalar and temporal regions are with implants. Malr shell and temporal implants will do well in those areas. Injectable fat grafting is another alternative, and the least costly one, but its reliability on someone on antiviral medication is very suspect. Even in a patient not on such medication, fat grafting is not always reliable anyway. Unfortunately, there are no treatment options that combine the concepts of ‘not short lasting and not expensive’ when it comes to facial volume restoration. Your best choice under these circumstances is fat grafting and one has to accept that it is unknown what will happen with volume persistence. Another option is to combine temporal implants with malar/submalar fat grafting. Temporal implants are the easiest and least costly of all facial implants to put in and can easily be done under IV sedation as can fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can you tell me if placing a temporal implant about 9mm thick under the temporal fascia, does this cause the eyes to appear smaller? Like does it pull the skin more to the temporal area and away from the eyes? It would be helpful for me to know, thanks.
A: That is an interesting question and one that I have never heard before. Temporal implants may push the skin in the temporal fossa outward but they do not cause any pull on the eyelid skin or the corner of the eye. Thus, temporal augmentation would not have any direct effect on the appearance of the eye. Whether it may secondarily cause the eye to appear smaller because of a more flat or convex temporal region is possible but not a complaint that has ever been voiced to me nor one that I have seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am going to have temporal implants next month and have a few questions. Will the silicone be cut and shaped after my physical consultation or prior? The reason I ask this is because the pictures I provided show less indentation than there is in reality. I feel I will need quite a thicker implant to fill the area especially since I would like the widest part of my face to shift from below my eyes to in level with my eyes or slightly higher.Will the implants be even with my zygoma arches? I have prominent cheekbones and because they’re a bit lower, they have made my face look short when I wear bangs. I would like my temples filled in to slightly wider than my cheekbones to make my face appear longer since right now it has the unwanted “hour glass” shape and separates the forehead from my lower half.Unfortunately I only have 48 hours to recover and this makes me nervous, can I take Sinnech 3 days prior to surgery?
A: Temporal implant sizing is done either the day before or just before surgery. There are two basic sizes of temporal implants. Most likely you will only require the smaller size given your face, stature and being female. That implant thickness is 6 to 7mms which is actually quite substantial when actually in place. Whether the implant needs to be reduced in any manner is determined during surgery if I feel that it might be too big or give too much fullness. The implant is placed under the fascia down to the zygomatic arches. In some cases, the fascia is actually released at that point to allow the fullness of the temporal implant to be in the same plane as that of the zygomatic arch tissues. Usually the recovery from temporal implants is quite quick. There is virtually no pain and minimal swelling. Bruising can occur if the fascia needs to be released. But if not there can be virtually none. But taking Sinnech before and after surgery is always a good idea.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I really like what you have done for my temporal augmentation. But I had read some bad reviews on silicone implants. Would you be able to do Gore-tex implants instead? I am weary of silicone…
A: I have no concerns about silicone facial implants and I don’t know where those ‘bad reviews’ come from. Your body doesn’t care if it is silicone, gore-tex or any other material, it treats them all the same…as a foreign body which is enveloped by a layer of scar tissue. (capsule) Any beliefs that the body treats one synthetic material different than another is not based on any known science of biomaterials.
That being said, it doesn’t make any difference to me what material a patient wants to use as long as it can do the job adequately. I almost always use silicone temporal implants because they are preformed, very soft and flexible and are the most economically efficient for the patient. I can certainly use Gore-tex but it will cost more because you have to buy a block of it and then hard carve out the implants during surgery. It is easy for me to do, it just costs more.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I desire a smoother, lower forehead. Currently I have indentations on each side of my forehead that run all the way down to my cheekbone arches. I would really like to have those indentations filled in using bone cement or some other reliable material. I also have a high forehead and would like to have it lowered. My forehead looks big and masculine right now and does not fit well with the rest of my face. I have attached pictures of me for your review.
A: The indentations to which you refer are the temporal fossa, which is largely a soft tissue space filled with the temporalis muscle to the side of the forehead. It extends from the anterior temporal line at the edge of the forehead down to the zygomatic arches inferiorly. While these could be filled in with bone cement deep under the muscle, that would not be my approach and could be improved much more simply. Silicone temporal implants can be placed under the deep temporal fascia and on top of the muscle. This is a more effective, reliable and cost effective technique.
When you speak to a large forehead, I am assuming you mean a high one in which the distance is vertically long from the eyebrows to the frontal hairline. That is different that a large forehead in which the frontal bone is bossing or prominent. While the forehead can be vertically shortened by a centimeter or so through a frontal hairline advancement and skin excision, I would be very cautious about performing that procedure in you. A forehead reduction results in a scar along the frontal hairline. In pigmented skin types like yours, I would be concerned about how such a scar may turn out. Hair density and hairstyle is also an important consideration is deciding about the aesthetic merits of a forehead reduction procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Wwhat kind of temporal implants do you use? I have read that Medpor temporal implants has to be screwed under the temporal muscle onto the temporal bone. Is that the way you do it? Will the scalp incisions be bad in that case? Thank you very much.
A: There are different indications for temporal augmentation and that determines the type of implant used and its location. For cosmetic augmentation and in mild muscle atrophy after a craniotomy, the implant is placed under the fascia (on top of the muscle) in most cases. I prefer the use of soft flexible silicone rubber temporal implants when it is placed in this more superficial location. This is done through a very small vertical incision in the temporal hairline that heals inconspicuously. In more severe atrophy cases after craniotomy or at the time of a craniotomy, the implant is placed next to the bone and often needs to be larger. This is where a Medpor temporal implant is used as it is meant to be placed next to the bone and is usually screwed into place. It is placed through an existing larger scalp coronal incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve heard that you perform temporal implants. Where does these implants go, is it under the superficial temporal fascia or the deep temporal fascia? I have heard the deep temporal fascia cannot stretch to cover an implant. Is that true? Also, does this implant reach down to the zygomatic arch and can these implants become infected? Thank you so much.
A: They are almmost always placed under the deep temporal fascia. There is no problem with the fascia stretching to cover it and the fascia is often released along the lateral orbital rim and superior zygomatic arch to accomodate bigger implants. I have rarely put temporal implants on top of the deep temporalis fascia as there is the possibility that the dissection or the pressure of the implant may injure the frontal branch of the facial nerve. The lower edge of temporal implants almost always extends down to the zygomatic arch. Like all facial implants, there is a risk of infection but this is usually very low around a 1% chance.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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
Indianapolis, Indiana
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.
Indianapolis, Indiana