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 DOI: 10.1177/1090820X11417425

2011 31: 827Aesthetic Surgery JournalChad R. Gordon and Michael J. Yaremchuk

Temporal Augmentation With Methyl Methacrylate  

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- Sep 9, 2011Version of Record >>

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Featured Operative Technique

Aesthetic Surgery Journal31(7) 827 –833© 2011 The American Society for Aesthetic Plastic Surgery, Inc.Reprints and permission: http://www .sagepub.com/journalsPermissions.navDOI: 10.1177/1090820X11417425www.aestheticsurgeryjournal.com

Concavity in the temporal area is often referred to as tem-poral hollowing. It reflects a deficiency in the bulk of the temporalis muscle or overlying temporal fat pad. When the temporal area has not been surgically violated, concav-ity gradually appears with senescence.1 It may appear in patients with low body fat (and hence less temporal fat). 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-poral area can have a rejuvenating effect and/or a balancing effect on facial appearance. Many patients who have undergone surgery in the temporal area are left with concavity, a deformity that may specifically arise after neurosurgical procedures that damage the integrity of the temporalis muscle during temporal or pterional craniotomy. Both aesthetic and reconstructive procedures that violate 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-plastic implants,3-5 free fat grafting,6 the injection and onlay of various absorbable and permanent materials,7-9 locoregional flaps,10-12 and, in some instances, free tissue

transfer.13,14 Here, we describe the application of methyl methacrylate (MMA) to fill depressions in the temporal area.15 In instances in which no previous surgery has been performed or when the temporal area has served as a dis-section plane for surgery in adjacent areas (eg, with a subperiosteal facelift), the implant material is placed

Temporal Augmentation With Methyl Methacrylate

Chad R. Gordon, DO; and Michael J. Yaremchuk, MD

AbstractConcavity 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 scalp. 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.

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

Accepted for publication January 5, 2011.

From the Division of Plastic & Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Corresponding Author:Dr. Yaremchuk, Division of Plastic & Reconstructive Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC #435, Boston, MA 02114, USA. E-mail: myaremchuk@partners.org

Scan this code with your smartphone to see the operative video. Need help? Visit www.aestheticsurgeryjournal.com.

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beneath the temporal muscle through a limited incision in the hair-bearing scalp. When previous reconstructive sur-gery has been performed in the temporal area and the temporalis anatomy has been distorted, the areas of depression are accessed through existing surgical incision scars. MMA is placed over the temporal and adjacent skel-eton, as necessary. These methods of placing MMA to reconstruct temporal contour depressions have been reli-able, durable, and relatively free of complications.

OperAtive techniqueAesthetic Indications

A vertical, 4- to 5-cm incision is made in the temporal scalp (Figures 1 and 2). This incision is placed just in front of and above the ear within the hair-bearing scalp. The scalp flap is undermined for 1 or 2 cm before the deep temporal fascia and underlying temporalis muscle are

Figure 1. This illustration shows the vertically-oriented 4- to 5-cm incision within the temporal hair-bearing scalp overlying the contour depression.

Figure 2. The proposed skin incision is shown in relation to deep temporal fascia and temporalis muscle.

Figure 3. (A) Axial views of skin undermining for 1 to 2 cm prior to dissecting a submuscular pocket with needle-tip electrocautery. (B) Pocket dissection should be limited to the superior edge of the zygomatic arch as shown.

Figure 4. (A) The methyl methacrylate acrylic is placed into the temporal submuscular pocket. (B) Closure includes approximation of the temporalis muscle, fascia, and skin.

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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 temporal bone.

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 mandible (Figure 4).

MMA is prepared by mixing the powder with the liquid material. While still in a liquid form, the MMA is placed in a 10-mL syringe. With a retractor elevating the muscle away from the bone, the material is injected into the sub-muscular pocket. Before the MMA hardens, it is molded into the desired shape by manipulating the overlying soft tissues so that they project to the same level as the lateral orbital rim (Figure 5).

The temporalis muscle and then the temporalis fascia are reapproximated before the scalp incision is sutured. No drains are placed. Figure 6 shows the clinical results of a patient treated with MMA for aesthetic indications.

Postreconstructive Indications

Temporal depressions may occur after certain neurosurgical procedures are performed in the temporal area.9 This includes situations in which freeing the temporalis muscle origins from the temporal crest or away from the lateral orbital rim is required. Muscle reattachment is difficult and often less than ideal, leading to significant depressions beneath the temporal line. The deficiency is exaggerated when the overlying soft tissues are thinned due to posttraumatic scarring or atrophy.

For this type of augmentation, scars from the previous surgical procedure are used (Figure 7). A scalp flap is

Figure 5. The methyl methacrylate is placed under the 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.

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raised, extending to the lateral orbital rim. The level of dissection is determined by the clinical situation but always respects the path of the frontal branch of the facial nerve. 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 point.

Prior to molding the implant, one or two titanium screws of 8 to 10 mm in length are placed in the lateral aspect of the lateral orbital rim, such that the screw head protrudes 4 to 5 mm from the surface of the rim. These screws will become embedded in the MMA and serve as anchors to prevent any movement of the implant (Figure 8). The MMA is prepared and allowed to cure until it is puttylike in consistency. It is then placed over any contour deficiencies to abut the orbital rim (Figure 9).

It is useful to place the scalp flap over the reconstructed area and mold the material through the overlying soft tis-sues as it hardens, encasing the protruding screw heads (Figures 10 and 11). This allows the MMA to also correct any deficiencies in the overlying scalp flap. Placing MMA beneath any scalp incision suture lines is avoided, if pos-sible, since any suture line breakdown would result in implant exposure. A suction drain is placed, which exits from a separate stab-wound incision. A mildly compres-sive tape dressing is applied over the non–hair–bearing area of reconstruction. Intravenous antibiotics are admin-istered perioperatively and then given enterally for five days postoperatively.

Figure 12 shows the clinical results of a patient treated with MMA for reconstructive indications. A video of the surgical procedure for reconstructive indications is avail-able at www.aestheticsurgeryjournal.com. You may also

use any smartphone to scan the code on the first page of this article to be taken directly to the video on www.you tube.com.

DiscussiOn

Similar to what was described by Ousterhout,15 we have found that it is better to undercorrect than to overcorrect the temporal contour. Almost any amount of material placed beneath the temporalis muscle results in a contour improvement. Augmentation beyond the normal limits of the temporal projection results in an easily-recognizable contour deformity. Ousterhout also recommended aug-menting one side at a time. Simultaneously augmenting areas on opposite sides of the head with a semi-liquid, rapidly-curing material is technically challenging and pre-disposes to contour imperfections resulting from gravita-tional and head-positioning effects on the curing material.

We have augmented the temporal area for aesthetic purposes 35 times over the last eight years. Of these, five patients underwent revisional surgery. Three of those patients had contour irregularities corrected by reducing prominences at the muscle closure site with a contouring burr. One patient deemed her temporal area too full after augmentation, and her implant was subsequently removed. One of the first patients in the series had the inferior bor-der of her implant reduced because it impinged on the coronoid process with maximum jaw opening. (In retro-spect, the submuscular pocket was dissected beyond the superior border of the zygomatic arch.) Removal of both implants required splitting the temporalis muscle in the direction of its fibers from temporal crest almost to the

Figure 7. The scar from a previous coronal incision is incised with elevation of the scalp flap to expose the lateral orbital rim. The temporal muscle is attenuated and detached from the temporal crest.

Figure 8. Two titanium screws are placed along the lateral orbital rim, with the screw heads protruding for 4 to 5 mm above the bone. As the methyl methacrylate dries, it encases the screws, which serve as anchors preventing movement of the implant.

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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 the attenuated temporalis muscle. Note that the MMA is encasing screws placed in the lateral orbital rim.

Figure 11. Manual molding of the methyl methacrylate implant prior to hardening.

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832 Aesthetic Surgery Journal 31(7)

zygomatic arch. In the series of 35 patients, there has been no instance of infection with MMA to augment the tempo-ral area for aesthetic or postcraniotomy indications.

cOnclusiOns

MMA augmentation is an effective means of restoring the contour of the temporal area. The material, which has been used for decades to reconstruct full-thickness defects of the skull vault, is biocompatible and easily moldable. It provides a predictable and permanent result. Placement of MMA in the submuscular pocket (unlike with preformed temporal implants, which are placed in a supramuscular plane) avoids any risk of damage to the frontal branch of the facial nerve.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

reFerences

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 for facial rejuvenation: aesthetic surgery of the facial skeleton. Clin Plast Surg 1991;18(1):197-203.

3. Lewis RP, Schweitzer J, Odum BC, et al. Sheets, 3-D strands, tridimensional (3-D) shapes, and sutures of either reinforced or nonreinforced expanded polytetra-fluoroethylene for facial soft-tissue suspension, augmen-tation, and reconstruction. J Long-Term Effects Medic Implants 1998;8(1):19-42.

4. Lin J, Chen X, Zhang W, Xu L, Zheng X. Temporal aug-mentation using a polytetrafluoroethylene implant with the assistance of an endoscope. Aesth Plast Surg 2010;8(2):3-7.

5. Atherton DD, Joshi N, Kirkpatrick N. Augmentation of temporal fossa hollowing with Mersilene mesh. J Plast Reconstr Aesth Surg 2010;63:1629-1634.

6. Fontdevilla J, Seraa-Renom JM, Raigosa M, et al. Assess-ing the long-term viability of facial fat grafts: an objec-tive measure using computed tomography. Aesthet Surg J 2008;28(4):380-386.

7. Sykes JM. Applied anatomy of the temporal region and forehead for injectable fillers. J Drugs Dermatol 2009;8(10 Suppl):S24-S27.

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.

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8. Ji C, Ahn JG. Clinical experience of the Brushite calcium phosphate cement for the repair and augmentation of surgically induced cranial defects following pterional cra-niotomy. J Korean Neurosurg Soc 2010;47(3):180-184.

9. Persing JA, Cronin AJ, Delashaw JB, et al. Late surgical treatment of unilateral coronal synostosis using methyl methacrylate. J Neurosurg 1987;66:793-799.

10. Rapidis AD, Day TA. The use of temporal polyethyl-ene implant after temporalis myofascial flap transposi-tion: clinical and radiographic results from its use in 21 patients. J Oral Maxillofac Surg 2006;6(1):12-22.

11. Guven E, Kuvat SV, Aydin HU, Yazar M, Emekli U. Facial contour reconstruction with temporoparietal pre-laminated dermal-adipose flaps. J Craniomaxillofac Surg 2010;38:374-378.

12. Ye XD, Li CY, Wang C, Yu YS. Superficial temporal fascial flap plus lipofilling for facial contour reconstruction in bilateral progressive facial hemiatrophy. Aesthetic Plast Surg 2010;34(4):534-537.

13. Valentini V, Gennaro P, Torroni A, et al. Scapula free flap for complex maxillofacial reconstruction. J Craniofac Surg 2009;20(4):1125-1131.

14. Vaienti L, Soresina M, Menozzi A. Parascapular free flap and fat grafts: combined surgical methods in morpholog-ical restoration of hemifacial progressive atrophy. Plast Reconstr Surg 2005;116(3):699-711.

15. Ousterhout DK. Aesthetic Contouring of the Craniofacial Skeleton. Boston: Little, Brown; 1991.

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