What Is The Best Surgical Method For Head Narrowing?

Q: Dr. Eppley, I saw you say this on your website: “When attempting to  reduce the width of the head (bitemporal/biparietal distance), it is usually necessary to do a combined muscle and bone reduction. Burring down the temporal bone is not as productive in regards to width reduction but still has a valuable role to play. The bone can usually be reduced up to 3 mm to 4mms per side.” When doing temporal reduction, do you usually do bone burring along with muscle removal?

If I want the best result of head narrowing, is surgical reduction of posterior temporal and  Botox injections on anterior temporal muscle the correct approach to do so? Usually how many treatments are needed to effectively narrow a forehead? I heard that Botox’s effect is only temporary, if one stops getting injections the muscles will become alive again. Is this true?

A: What I have to be most effective for posterior temporal reduction to change the convexity of the head above the ears is complete removal of the posterior temporal muscle belly. It is an incredibly thick muscle that often is 7mm to 9mm thick per side. There are no functional issues with doing so and I have done it a large number of times so i have unique insight into that issue. That does more for changing the head width convexity that any temporal bone reduction. This contrary to what people and surgeons think but that has been my experience.

Whether I do any posterior temporal bone reduction at all with the muscle excision largely depends on the incisional approach. If the patient wants a ‘scarless’ method by using an incision that stays in the post auricular sulcus bend the ear then no bone reduction is done due to access. If the patient wants bone reduction also and does not mind a small vertical temporal hairline incision then I will do so.

For anterior temporal width reduction (besides the eye and in the anterior the temporal hairline), particularly in the muscle area above the zygomatic arch, only Botox injections can be used. However if one is getting any type of forehead procedure where surgical access can be had to the upper anterior temporal zone, muscle release and resection can be done to drop the upper anterior temporal muscle fullness and reduce the temporal line/lateral forehead bone to make the forehead more narrow.

The effect of Botox on masticatory muscles, like the temporalis and masseter muscles, can have a profound effect on shrinking muscle mass. The only question is how many times does it need to be done and how permanent can the result be. That is highly variable in my observation with some sustained permanency in some patients and only a temporary effect in others.

Dr. Barry Eppley

Indianapolis, Indiana