Chapter 6 Filler Injection of the Temporal Region



10.1055/b-0040-178124

Chapter 6 Filler Injection of the Temporal Region



Introduction


The temporal region is delimited superiorly by the temporal line (temporal suture), inferiorly by the zygomatic arch, anteriorly by the external orbital rim, and laterally by the hairline (Fig. 6.8).


In a young person, the temples are flat or slightly convex, but they become concave with age. The upper third of the face narrows, which causes apparent shortening and the ptosis of the eyebrow, with the tail of the eyebrow “falling” into the temporal region. 1 According to Raspaldo, 2 the degree of aging of the temporal region can be classified into four stages, characterized as follows (Fig. 6.9):




  1. Convex or flat temporal fossa.



  2. Slight depression.



  3. Concavity of the temporal fossa, some visibility of vessels, and ptosis of the tail of the eyebrow.



  4. Skeletization of the temporal fossa and visible bones, clear visibility of vessels, and severe concavity.



Anatomy


The temporal region is composed of the skin, subcutaneous tissue, superficial temporal fascia or temporoparietal fascia, temporal fat pad, deep temporal fascia (divided into the superficial and deep layers), buccal fat pad (Bichat’s fat pad), temporal muscle, and periosteum of the temporal bone (Fig. 6.46.7 and6.106.19). 3


The superficial temporal artery (STA) and the deep temporal artery supply this region. The STA is the smaller of the two terminal branches of the external carotid artery. It originates in the parotid gland, posteriorly to the neck of the mandible, and crosses the zygomatic arch about 10 mm anteriorly to the tragus. It divides into the transverse facial artery, the zygomatico-orbital artery, and the parietal and frontal branches. It crosses the temporal region in its posterior quadrant and above the superficial temporal fascia. The deep temporal artery is a branch of the maxillary artery, the largest of the terminal branches of the external carotid. It has an anterior and a posterior branch, located between the temporal muscle and the periosteum. It is important to note that despite being a branch of the external carotid, the STA anastomoses with branches of the internal carotid, such as the supraorbital artery. Therefore, an intravascular injection could reach the internal carotid system through retrograde flow and occlude the central retinal artery. Though rare, the main complication is blindness. It is, therefore, vital to have in-depth knowledge of the local anatomy and the appropriate technique before performing any procedures in this region.


The periorbital veins, the frontal branch of the superficial temporal vein (STEV), the branches that drain from the temporal muscle, the zygomatico-orbital and zygomaticotemporal veins, and the sentinel vein drain to the middle temporal vein (MTV), which crosses the temporal region between the superficial and deep layers of the deep temporal fascia. The MTV anastomoses with the STEV above the zygomatic arch and connects with the cavernous sinus through the periorbital veins, which is why there is a risk of embolization in the cavernous sinus after intravenous injection. 4 ,. 5



Technique


The techniques used are divided into superficial and deep techniques (Fig. 6.206.36). The basic steps for either technique consist of:




  • Marking the area to be filled and observing that the temporal fossa is frequently deeper in the region immediately lateral to the orbit and above the zygomatic arch.



  • Choosing the most appropriate hyaluronic acid (HA): To do this, it is important to assess the thickness of the local skin, application plane, and degree of aging.



Superficial Technique


This technique involves performing a retrograde injection in the subcutaneous tissue through a microcannula, using HA for the superficial or middermis. Administer the injection below the visible vessels; the volume used depends on the degree of aging. Generally, 1 ml per side is used. Massage the area well (Fig. 6.1).


Treating the temporal region is a challenge because the local skin is thin and tends to form irregularities after injection. Lambros 1 presented an alternative technique for filling the subcutaneous plane with HA diluted in physiological saline solution (PS) at a ratio of 2:1 (PS to HA). With the absorption of PS, HA is distributed more uniformly. This dilution technique, and inserting HA at this site, is considered off -label.

Fig. 6.1 Pierce the skin and subcutaneous tissue with the microcannula until you reach the superficial temporal fascia where hyaluronic nacid (HA) is deposited.


Deep Technique


Deposit the HA bolus for the middermis and deep dermis or the volumizer below the temporal muscle, in the supraperiosteal plane. Insert the needle perpendicularly to the skin, until you reach the periosteum. Aspire, inject slowly, and do not move the needle during the injection. Generally, 0.5 to 1 ml per side is used, and the site of injection should be massaged well (Fig. 6.2).


The Swift technique for deep filling of the temporal region involves inserting the needle perpendicularly (1 cm above the external orbital rim and 1 cm below the temporal suture) until the periosteum is reached. This technique is considered safer because the deep temporal artery and the STA do not flow through this region. 4

Fig. 6.2 The needle crosses the skin, subcutaneous tissue, superficial temporal fascia, deep temporal fascia, and temporal muscle, and then reaches the periosteum where hyaluronic acid (HA) is deposited. A 27 Gx 13 mm (or longer) needle should be used for filler injections in the supraperiosteal plane.

Table 6.1 shows the main differences between the two techniques described. When necessary, both can be used on the same patient. This is called a combined technique (Fig. 6.3).


























Table 6.1 Characteristics of the superficial and deep techniques

Superficial technique


Deep technique


Injection with microcannula


Injection with needle


Application technique: linear retrograde injection


Application technique: bolus


Subcutaneous injection plane


Supraperiosteal injection plane


Hyaluronic acid in the


Hyaluronic acid in the


middermis/deep dermis (with or without dilution)


middermis/deep dermis or volumizer



Complications


Common adverse effects include edema, which can last up to 72 hours; temporary congestion of the local vessels; irregularities; hematoma; and pain at the site of injection. Serious complications, such as embolism and thrombosis, have also been reported.

Fig. 6.3 Simulation of a superficial filler injection in the subcutaneous tissue with a microcannula, above the superficial temporal fascia, and a deep injection below the temporal muscle in the supraperiosteal plane.


References

1 Lambros V. A technique for filling the temples with highly diluted hyaluronic acid: the “dilution solution”. Aesthet Surg J 2011;31(1):89–94 2 Raspaldo H. Temporal rejuvenation with fillers: global faceculpture approach. Dermatol Surg 2012;38(2):261–265 3 Radlanski RJ, Wesker KH. The face: pictorial atlas of clinical anatomy. London: Quintessence Publishing; 2012 4 Sykes JM, Cotofana S, Trevidic P, et al. Upper face: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg 2015; 136(5, Suppl):204S–218S 5 Jung W, Youn KH, Won SY, Park JT, Hu KS, Kim HJ. Clinical implications of the middle temporal vein with regard to temporal fossa augmentation. Dermatol Surg 2014;40(6):618–623
Fig. 6.4 Frontal view of the anatomy of the temporal region.
Fig. 6.5 Frontal view of the vascularization and innervation of the temporal region.
Fig. 6.6 Anatomy of the temporal region.A. Lateral view of the face.B. Subcutaneous tissue after removal of the skin.C. Superficial temporal fascia after removal of the subcutaneous tissue.D. Temporal fat pad, below the superficial temporal fascia and above the deep temporal fascia.E. Buccal fat pad (Bichat’s fat pad) below the deep temporal fascia and above the temporal muscle.F. Temporal bone.
Fig. 6.7 Lateral view of the vascularization and innervation of the temporal region.A. Cranium with the corresponding vascularization and innervation.B. Cranium with the corresponding arterial vascularization.C. Cranium with the corresponding venous vascularization.D. Cranium with the corresponding vascularization above the muscles of the upper and middle thirds of the face.E. Cranium with the corresponding vascularization over the muscles of the upper and middle thirds of the face. The superficial temporal fascia has been folded back, revealing the vascularization over the deep fascia.F. Cranium with the corresponding sensorimotor innervation.
Fig. 6.8 Delimitation of the temporal region.
Fig. 6.9 Volume loss in the temporal region at a scale of 1:4.
Fig. 6.10 A andB. Left side of the face of a fresh cadaver specimen with the skin being folded back.C andD. Exposure of the subcutaneous tissue of the temporal region.
Fig. 6.11 A. Subcutaneous tissue of the temporal region being folded back on a fresh cadaver.B. Anterior branch of the superficial temporal artery (STA) and temporal branch of the facial nerve exposed.C. Close-up of the temporal branch of the facial nerve.D. Close-up of the anterior branch of the STA.
Fig. 6.12 A, B, andC. Right side of the face of a fresh cadaver specimen with the skin being folded back.D. Superficial temporal artery (STA) (black arrow) and its anterior branch (blue arrow) .
Fig. 6.13 A. Superficial temporal fascia being pinched, deep temporal fascia below, and at the bottom, the temporal muscle.B. Close-up ofA.
Fig. 6.14 A, B, andC. Right side of the face of a fresh cadaver specimen with the skin being folded back.D andE. Anterior branch of the superficial temporal artery (STA) being pinched.
Fig. 6.15 A. Right lateral view of a fresh cadaver specimen showing the parietal and frontal branches of the superficial temporal artery (STA), located above the subcutaneous tissue. Frontal branch of the STA being pinched.B. Illustration corresponding to imageA.C. Frontal branch of the STA being pinched. Subcutaneous tissue and superficial temporal fascia have been folded back to reveal the deep temporal fascia, which has also been pinched, with the middle temporal vein (MTV) branches visible through the skin.D. Illustration corresponding to imageC.E. Superficial and deep temporal fascias being folded back exposing the temporal vein branches. These are above the extension of the buccal fat pad (Bichat’s fat pad) and the temporal muscle. Exposure of the MTV branches.F. Illustration corresponding to imageE.
Fig. 6.16 A. Right side of the face of a fresh cadaver specimen showing the superficial temporal artery (STA); superficial and deep temporal fascias folded back exposing the temporal vein branches. Extension of the buccal fat pad (Bichat’s fat pad) being pinched revealing the temporal muscle below.B. Illustration corresponding to imageA.C. Right side of the face of a fresh cadaver specimen showing the temporal muscle being folded back.D. Illustration corresponding to imageC.E. After folding back the temporal muscle, the periosteum and temporal bone are visible. Extensions of the temporal vein branches are visible in the deep planes and the supraperiosteal arterioles.F. Illustration corresponding to imageE.
Fig. 6.17 A. Right temporal region of a fresh cadaver specimen showing the superficial temporal artery (STA). The frontal branch of the superficial temporal vein (STEV) anastomosing with the sentinel vein is also visible.B. Illustration corresponding to imageA.
Fig. 6.18 A. Temporal vein branches located above the temporal muscle.B. Illustration corresponding to imageA.
Fig. 6.19 A. Deep temporal fascia being pinched in the temporal region. The temporal muscle is visible below it.B. Temporal muscle being folded back to reveal the temporal fossa.C. Layers of the temporal region: skin, subcutaneous tissue, temporal fat pad, superficial temporal fascia (blue arrow), deep temporal fascia, temporal muscle, and periosteum of the temporal bone.
Fig. 6.20 Profile of a model on whom the temporal region has been marked and divided into quadrants. The superomedial quadrant (blue arrow) is the best for deep supraperiosteal filler injections of the temporal region.
Fig. 6.21 A. Superior quadrant of a model with indication of bilateral temporal filler injection.B. Close-up ofA, showing the right temporal region presenting significant concavity.
Fig. 6.22 Profile of a model on whom the temporal region has been marked and showing correct insertion of a 25 Gx 40 mm microcannula between the inferomedial and lateral quadrants. The temporal subcutaneous tissue can be filled with the microcannula through this entry point.
Fig. 6.23 A. Left side of the face of a fresh cadaver specimen with microcannula inserted into the temporal subcutaneous tissue. The position of the microcannula is visible on the skin, showing the superficiality of this application plane.B. Skin has been folded back showing how the temporal subcutaneous tissue is being filled with a microcannula.
Fig. 6.24 A. Profile of a model on whom the temporal region has been marked and showing correct insertion of a 25 GX 40 mm microcannula between the inferomedial and lateral quadrants. The superior and inferior lateral temporal regions are filled through this entry point.B. Correct insertion of the 25 GX 40 mm microcannula between the lateral and inferomedial quadrants. The superior and inferior temporal regions are filled through this entry point.C. Correct insertion of the 25 GX 40 mm microcannula between the lateral and inferomedial quadrants. The superior and inferomedial temporal regions are filled through this entry point. It is also possible to fill the tail of the eyebrow with the microcannula in this position.
Fig. 6.25 A. Right side of the face of a fresh cadaver specimen with microcannula inserted into the temporal subcutaneous tissue. The position of this microcannula is visible on the skin.B. Skin folded back and microcannula in the temporal subcutaneous tissue simulating a superficial filler injection in this area. Theblue arrow indicates the anterior branch of the superficial temporal artery (STA).C. Skin folded back and microcannula in the superficial temporal fat pad simulating a superficial filler injection in this area. It is also possible to fill the tail of the eyebrow when the microcannula is in this medial position, below the orbital portion of the orbicular muscle. Theblue arrow indicates the anterior branch of the STA.
Fig. 6.26 A. Layers of the temporal region: skin, subcutaneous tissue, superficial temporal fascia(blue arrow), superficial temporal fat pad, deep temporal fascia, temporal muscle, and periosteum.B. Simulation of superficial temporal filler injection with a 25 GX 40 mm microcannula inserted into the temporal subcutaneous tissue, showing the application oflight green-colored hyaluronic acid (HA).
Fig. 6.27 Profile of a model on whom the temporal region has been marked and showing insertion of a 27 Gx 13 mm needle in the superomedial quadrantin green. The needle reaches the supraperiosteal plane, where the product should be applied. The superomedial quadrant is the best for deep temporal filler injections, as even with a short needle it is possible to reach the periosteum as it is shallower than the temporal fossa. Moreover, theoretically, there are no vascular structures in the supraperiosteal plane of this quadrant.
Fig. 6.28 A,B Left side of the face of a fresh cadaver specimen with the skin folded back and a 27 GX 13 mm needle inserted in the superomedial temporal region, simulating a filler injection of the temporal supraperiosteum. Theblue arrow indicates the anterior branch of the superficial temporal artery (STA).
Fig. 6.29 A. Left side of the face of a fresh cadaver specimen with the skin folded back and a 27 GX 13 mm needle inserted in the superomedial temporal region, simulating a filler injection of the temporal supraperiosteum. Hyaluronic acid (HA) was colored pink, as can be seen in the syringe.B. Skin folded back and dissection of the temporal region showing thepink HA that was injected inA.
Fig. 6.30 A. Layers of the temporal region: skin, subcutaneous tissue, superficial temporal fascia (blue arrow), superficial temporal fat pad, deep temporal fascia, temporal muscle, and periosteum of the temporal bone.B. Simulation of deep supraperiosteal temporal filler injection with a needle. The layers of the temporal region are visible, and the needle reaches the periosteum, where thegreen hyaluronic acid (HA) was injected.
Fig. 6.31 A, B, andC. Profile of a model on whom the temporal region has been marked and showing insertion of a 27 GX 13 mm needle in the inferomedial, lateral superior, and lateral inferior quadrants, respectively. The needle reaches the supraperiosteal plane, and the product is applied to this region. The superomedial quadrant is the best location for deep temporal filler injections because, even with a short needle, it is possible to reach the periosteum, as it is shallower than the temporal fossa. Moreover, theoretically, there are no vascular structures in the supraperiosteal plane of this quadrant. Although it is possible to administer a filler injection to the quadrants illustrated inFigs. 6.24 A, B, and C, this is not advisable because the superficial temporal artery (STA) flows through the posterior quadrants and the deep temporal artery branches through the inferior ones.
Fig. 6.32 A. Demonstration of the deep injection technique using a needle in the supraperiosteal plane, in the superomedial quadrant of the left temporal region of a fresh cadaver specimen, and cranium. Note that the needle is inserted perpendicularly at the site of injection.B. Left temporal region of a fresh cadaver specimen, with temporal muscle folded back, showing the supraperiosteal plane of the temporal bone. Theblue arrow on the sample points to the superomedial quadrant of the temporal region, where there is less risk of perforating the vessels. Theblue dot shows the point in the cranium where the product was injected.
Fig. 6.33 A. Thered dot on the superomedial quadrant indicates the area that needs to be filled.B. Injection of the product with a needle positioned perpendicularly to the skin on the deep plane.C. Skin of the temporal region being folded back.D. Green product located on the supraperiosteal plane of the superomedial quadrant of the temporal region.
Fig. 6.34 Visualization of the product (in green), located on the supraperiosteal plane of the superomedial quadrant of the temporal region, below the temporal muscle. Note that there are few vessels in this area.
Fig. 6. 35 A. Layers of the temporal region: skin, subcutaneous tissue, superficial temporal fascia(blue arrow), superficial temporal fat pad, deep temporal fascia, temporal muscle, and periosteum.B. Simulation of deep supraperiosteal temporal filler injection with a needle and simulation of superficial temporal filler injection with a microcannula. Note the layers of the temporal region and the 25 Gx 40 mm microcannula inserted into the subcutaneous tissue, simulating the application oflight green-colored hyaluronic acid (HA). HA of the same color is visible in the supraperiosteal plane.
Fig. 6.36 A. Right temporal region of a model with indication of filler injection. Marked concavity of the region is visible, revealing a serious loss of volume.B. Right temporal region after administration of a filler injection with hyaluronic acid (HA) using a combined technique with a needle on the supraperiosteal plane and microcannula on the superficial plane. The tail of the eyebrow and the frontal region were also filled.

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Sep 28, 2020 | Posted by in Aesthetic plastic surgery | Comments Off on Chapter 6 Filler Injection of the Temporal Region
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