54.1 Preoperative Steps

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  Analysis is the key to successful treatment. Understand the course of the facial nerve (Fig. 54.1a, b).

  
  
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  Aging frequently results in hollowing of temples with exposure of the lateral orbit and visibility of the temporal fusion line, which gives the head and face a gaunt narrow look. The tails of the brows appear short and low as they follow the reduced radius of curvature of the temple.

  
  
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  One of the major effects of filling the temple is the lengthening and apparent elevation of the tail of the brow.

  
  
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  Ideally temples should be flat, neither concave nor convex.

  
  
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  It is important to note the position of the temporal artery, which can often be seen and confirmed by palpation. If there is doubt, a Doppler is useful to map out any branches traversing the temple (Fig. 54.2a–c).

  
  
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  The decision to inject the temples is based on whether the patient likes the look of fuller temples.

  
  
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  Because the benefit of temple injection is a visual concept, not easily understood when described verbally, I like to inject the temple with a few cubic centimeters of dilute local anesthetic to show the patient and myself the desired effect (and for pain and hemostasis as well). This is like trying on clothes before buying them and patients uniformly like the idea of being able to see the result before committing to the injection; moreover, the patient now gets to make the decision about the procedure in a truly informed way. The injection of product follows this “preview.” Typically, 1.5 to 2 cc of the product is used per side.

  
  
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  At the time of writing this, I prefer Juvederm Ultra.

  
  
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  The success of any filler treatment depends on careful and thoughtful distribution.

  
  
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  The temple has three distinct areas: the main hollow of the temple, the tail of the brow, and a small vertical hollow frequently seen inferior to the tail of the brow.

  
  
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  There are two main methods for injecting temples: a periosteal transmuscular approach and a subcutaneous/subgaleal (subtemporoparietal fascia) approach, which I prefer for its smoothness and longevity.

  
  
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  The periosteal transmuscular approach places the filler in a single bolus placed on the periosteum 1 cm posterior and 1 cm superior to the inferior origin of the temporal fusion line at the lateral orbit. This approach, although easy, direct, and convenient, only addresses the superior portion of the temple hollow and tail of the brow. Duration of HA fillers with this approach is around 6 months in my experience, considerably shorter than the subcutaneous/subgaleal approach.

  
  
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  Longevity of effect in the subcutaneous/subgaleal plane is almost always greater than 2 years; 3 years is not uncommon. Since the product is distributed over the whole temple and lateral brow, it covers a wider area very smoothly.