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Temporal Augmentation With Methyl Methacrylate Chad R. Gordon and Michael J. Yaremchuk Aesthetic Surgery Journal 2011 31: 827 DOI: 10.1177/1090820X11417425

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Aesthetic Surgery Journal 31(7) 827–833­ Temporal Augmentation With Methyl © 2011 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: Methacrylate http://www.sagepub.com/​ journalsPermissions.nav DOI: 10.1177/1090820X11417425 www.aestheticsurgeryjournal.com Chad R. Gordon, DO; and Michael J. Yaremchuk, MD

Abstract Concavity in the temporal area reflects a deficiency in the bulk of the temporalis muscle or overlying temporal fat pad. It may be a reflection of senescence, low body fat, exaggerated adjacent skeletal or soft-tissue contours, idiopathic progressive atrophy, or postsurgical deformities. The authors describe the application of methyl methacrylate (MMA) to fill depressions in the temporal area. In instances in which no previous surgery has been performed or when the temporal area has served as a dissection plane for surgery in adjacent areas (eg, a subperiosteal facelift), the implant material is placed beneath the temporal muscle through a limited incision in the hair-bearing . When previous reconstructive surgery has been performed in the temporal area, the area of depression is accessed through existing surgical incision scars to place MMA over the temporal muscle. These operative techniques have been reliable, durable, and relatively free of complications.

Keywords temporal hollowing, temporal atrophy, temporal augmentation, methyl methacrylate, facial contouring

Accepted for publication January 5, 2011.

Concavity in the temporal area is often referred to as tem- transfer.13,14 Here, we describe the application of methyl poral hollowing. It reflects a deficiency in the bulk of the methacrylate (MMA) to fill depressions in the temporal temporalis muscle or overlying temporal fat pad. When area.15 In instances in which no previous surgery has been the temporal area has not been surgically violated, concav- performed or when the temporal area has served as a dis- ity gradually appears with senescence.1 It may appear in section plane for surgery in adjacent areas (eg, with a patients with low body fat (and hence less temporal fat). subperiosteal facelift), the implant material is placed In other healthy patients, prominent adjacent skeletal structures may diminish the relative projection of the tem- poral soft tissues, so augmenting the contours of the tem- From the Division of Plastic & Reconstructive Surgery, Department poral area can have a rejuvenating effect and/or a of Surgery, Massachusetts General Hospital, Harvard Medical School, balancing effect on facial appearance. Many patients who Boston, Massachusetts. have undergone surgery in the temporal area are left with Corresponding Author: concavity, a deformity that may specifically arise after Dr. Yaremchuk, Division of Plastic & Reconstructive Surgery, neurosurgical procedures that damage the integrity of the Massachusetts General Hospital, 15 Parkman Street, WACC #435, temporalis muscle during temporal or pterional craniotomy. Boston, MA 02114, USA. Both aesthetic and reconstructive procedures that violate E-mail: [email protected] the temporal fat pad may result in temporal hollowing. Temporal augmentation can restore the preoperative appearance of these patients, regardless of etiology.2 Numerous techniques have been described to augment the temporal area, including the placement of various allo- Scan this code with your plastic implants,3-5 free fat grafting,6 the injection and smartphone to see the operative onlay of various absorbable and permanent materials,7-9 video. Need help? Visit locoregional flaps,10-12 and, in some instances, free tissue www.aestheticsurgeryjournal.com.

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Figure 1. This illustration shows the vertically-oriented Figure 2. The proposed skin incision is shown in relation to 4- to 5-cm incision within the temporal hair-bearing scalp deep and temporalis muscle. overlying the contour depression.

Figure 3. (A) Axial views of skin undermining for 1 to 2 Figure 4. (A) The methyl methacrylate acrylic is placed cm prior to dissecting a submuscular pocket with needle-tip into the temporal submuscular pocket. (B) Closure includes electrocautery. (B) Pocket dissection should be limited to the approximation of the temporalis muscle, fascia, and skin. superior edge of the as shown. beneath the temporal muscle through a limited incision in Oper ative Technique the hair-bearing scalp. When previous reconstructive sur- gery has been performed in the temporal area and the Aesthetic Indications temporalis has been distorted, the areas of depression are accessed through existing surgical incision A vertical, 4- to 5-cm incision is made in the temporal scars. MMA is placed over the temporal and adjacent skel- scalp (Figures 1 and 2). This incision is placed just in front eton, as necessary. These methods of placing MMA to of and above the within the hair-bearing scalp. The reconstruct temporal contour depressions have been reli- scalp flap is undermined for 1 or 2 cm before the deep able, durable, and relatively free of complications. temporal fascia and underlying temporalis muscle are

Downloaded from aes.sagepub.com at JOHNS HOPKINS UNIVERSITY on August 6, 2014 Gordon and Yaremchuk 829 incised (Figure 3). Dissection is carried through the deep temporal fascia, providing visualization of the vertically- oriented temporalis muscle. The muscle is split in the direction of its fibers down to the . After visualizing the temporal bone, a pocket is dis- sected beneath the temporalis muscle. The dissection is carried out directly on the bone with the coagulation mode of an electrocautery instrument. Hemostasis in this setting of implant reconstruction is very important. The dimen- sions of the pocket will determine the area of augmenta- tion. For aesthetic indications, the area of undermining will extend from the lateral orbital rim anteriorly to just behind the hairline posteriorly. Vertically, it extends from the temporal crest to the zygomatic arch. It should not extend beneath the zygomatic arch, to prevent the implant from impinging on the condyle or coronoid process of the Figure 5. The methyl methacrylate is placed under the (Figure 4). temporalis muscle.

Figure 6. (A) This 35-year-old man was displeased with the asymmetries and imbalances of his facial contour. He felt that his temporal hollowing exaggerated the excessive width of his preauricular contour. (B) Six months after the latter of two procedures in which he underwent augmentation of the posterior/inferior mandible, augmentation of the infraorbital rim, superficial parotidectomy, facelift, and temporal augmentation with submuscular methyl methacrylate.

MMA is prepared by mixing the powder with the liquid Postreconstructive Indications material. While still in a liquid form, the MMA is placed in a 10-mL syringe. With a retractor elevating the muscle Temporal depressions may occur after certain neurosurgical away from the bone, the material is injected into the sub- procedures are performed in the temporal area.9 This includes muscular pocket. Before the MMA hardens, it is molded situations in which freeing the temporalis muscle origins from into the desired shape by manipulating the overlying soft the temporal crest or away from the lateral orbital rim is tissues so that they project to the same level as the lateral required. Muscle reattachment is difficult and often less than orbital rim (Figure 5). ideal, leading to significant depressions beneath the temporal The temporalis muscle and then the temporalis fascia line. The deficiency is exaggerated when the overlying soft are reapproximated before the scalp incision is sutured. No tissues are thinned due to posttraumatic scarring or atrophy. drains are placed. Figure 6 shows the clinical results of a For this type of augmentation, scars from the previous patient treated with MMA for aesthetic indications. surgical procedure are used (Figure 7). A scalp flap is

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Figure 7. The scar from a previous coronal incision is Figure 8. Two titanium screws are placed along the lateral incised with elevation of the scalp flap to expose the lateral orbital rim, with the screw heads protruding for 4 to 5 mm orbital rim. The temporal muscle is attenuated and detached above the bone. As the methyl methacrylate dries, it encases from the temporal crest. the screws, which serve as anchors preventing movement of the implant. raised, extending to the lateral orbital rim. The level of use any smartphone to scan the code on the first page of dissection is determined by the clinical situation but this article to be taken directly to the video on www.you always respects the path of the frontal branch of the facial tube.com. . If the temporalis muscle is retracted (resulting in a prominence below the depression), the muscle is mobi- lized and reattached with cortical tunnels as a fixation Discussion point. Prior to molding the implant, one or two titanium Similar to what was described by Ousterhout,15 we have screws of 8 to 10 mm in length are placed in the lateral found that it is better to undercorrect than to overcorrect aspect of the lateral orbital rim, such that the screw head the temporal contour. Almost any amount of material protrudes 4 to 5 mm from the surface of the rim. These placed beneath the temporalis muscle results in a contour screws will become embedded in the MMA and serve as improvement. Augmentation beyond the normal limits of anchors to prevent any movement of the implant (Figure the temporal projection results in an easily-recognizable 8). The MMA is prepared and allowed to cure until it is contour deformity. Ousterhout also recommended aug- puttylike in consistency. It is then placed over any contour menting one side at a time. Simultaneously augmenting deficiencies to abut the orbital rim (Figure 9). areas on opposite sides of the head with a semi-liquid, It is useful to place the scalp flap over the reconstructed rapidly-curing material is technically challenging and pre- area and mold the material through the overlying soft tis- disposes to contour imperfections resulting from gravita- sues as it hardens, encasing the protruding screw heads tional and head-positioning effects on the curing material. (Figures 10 and 11). This allows the MMA to also correct We have augmented the temporal area for aesthetic any deficiencies in the overlying scalp flap. Placing MMA purposes 35 times over the last eight years. Of these, five beneath any scalp incision suture lines is avoided, if pos- patients underwent revisional surgery. Three of those sible, since any suture line breakdown would result in patients had contour irregularities corrected by reducing implant exposure. A suction drain is placed, which exits prominences at the muscle closure site with a contouring from a separate stab-wound incision. A mildly compres- burr. One patient deemed her temporal area too full after sive tape dressing is applied over the non–hair–bearing augmentation, and her implant was subsequently removed. area of reconstruction. Intravenous antibiotics are admin- One of the first patients in the series had the inferior bor- istered perioperatively and then given enterally for five der of her implant reduced because it impinged on the days postoperatively. coronoid process with maximum jaw opening. (In retro- Figure 12 shows the clinical results of a patient treated spect, the submuscular pocket was dissected beyond the with MMA for reconstructive indications. A video of the superior border of the zygomatic arch.) Removal of both surgical procedure for reconstructive indications is avail- implants required splitting the temporalis muscle in the able at www.aestheticsurgeryjournal.com. You may also direction of its fibers from temporal crest almost to the

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Figure 9. (A) This aerial intraoperative photograph shows a preexisting craniotemporal depression of the left temporal and lateral frontal areas following a surgical intervention for frontal bone and intracranial injury. Aerial (B) and oblique (C) intraoperative views show supramuscular methyl methacrylate correction of temporofrontal deformity.

Figure 10. The methyl methacrylate (MMA) overlies Figure 11. Manual molding of the methyl methacrylate the attenuated temporalis muscle. Note that the MMA is implant prior to hardening. encasing screws placed in the lateral orbital rim.

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Figure 12. (A) This 36-year-old woman had undergone craniotomy to repair a cerebral aneurysm. The temporal bone flap had not been replaced anatomically, and the temporal muscle had retracted from the temporal crest, resulting in a temporal depression. (B) One year after a procedure was conducted through the existing neurosurgical scars to reattach the temporal muscle and fill the area of depression with methyl methacrylate, placed over the temporal muscle and adjacent structures.

zygomatic arch. In the series of 35 patients, there has been References no instance of infection with MMA to augment the tempo- ral area for aesthetic or postcraniotomy indications. 1. Whitaker LA. Temporal and malar-zygomatic reduction and augmentation. Clin Plast Surg 1991;18(1):55-64. 2. Whitaker LA, Bartlett SP. Skeletal alterations as a basis Conclusions for facial rejuvenation: aesthetic surgery of the facial skeleton. Clin Plast Surg 1991;18(1):197-203. MMA augmentation is an effective means of restoring the 3. Lewis RP, Schweitzer J, Odum BC, et al. Sheets, 3-D contour of the temporal area. The material, which has strands, tridimensional (3-D) shapes, and sutures of been used for decades to reconstruct full-thickness defects either reinforced or nonreinforced expanded polytetra- of the skull vault, is biocompatible and easily moldable. It fluoroethylene for facial soft-tissue suspension, augmen- provides a predictable and permanent result. Placement of tation, and reconstruction. J Long-Term Effects Medic MMA in the submuscular pocket (unlike with preformed Implants 1998;8(1):19-42. temporal implants, which are placed in a supramuscular 4. Lin J, Chen X, Zhang W, Xu L, Zheng X. Temporal aug- plane) avoids any risk of damage to the frontal branch of mentation using a polytetrafluoroethylene implant the facial nerve. with the assistance of an endoscope. Aesth Plast Surg 2010;8(2):3-7. Disclosures 5. Atherton DD, Joshi N, Kirkpatrick N. Augmentation of hollowing with Mersilene mesh. J Plast The authors declared no potential conflicts of interest with Reconstr Aesth Surg 2010;63:1629-1634. respect to the research, authorship, and publication of this 6. Fontdevilla J, Seraa-Renom JM, Raigosa M, et al. Assess- article. ing the long-term viability of facial fat grafts: an objec- tive measure using computed tomography. Aesthet Surg J Funding 2008;28(4):380-386. 7. Sykes JM. Applied anatomy of the temporal region and The authors received no financial support for the research, forehead for injectable fillers. J Drugs Dermatol 2009;8(10 authorship, and publication of this article. Suppl):S24-S27.

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