Dr Sam Robson and Qura Shah explain how the temple ages and share advice on successfully rejuvenating the area using filler
The temple forms the lateral boundary of the periorbital region of the upper third of the face. The cumulative effects of age are particularly apparent in this area, making it a common target for aesthetic rejuvenation. The youthful face is full, convex and usually round or oval in shape with uniform distribution of subcutaneous and deep fatty tissue.1 There is a morphological loss of fullness with age, relating to both skeletal changes and soft-tissue atrophy, particularly in the temporal and buccal regions.2 There is a tendency for the shape of the face to become gradually more ‘monkey-nutshaped’ rather than the round or oval shape commonly seen during youth, giving rise to a more skeletal appearance.2
The neonatal skull is characterised by a significantly large cranium in relation to the facial skeleton. With age, remodelling of the craniofacial skeleton occurs, during which selective deposition and resorption of bone allow the infant skull to widen and elongate in order to take on the adult form.3
Facial skeletal remodelling is a dynamic process continuing throughout the adult lifespan and becoming most notable after the third decade. After about 50 years of age, the human adult skull begins to take on similar features to the infant skull, with a gradual decrease in its size.2
The change in the rate of bone deposition and resorption leads to a decrease in the maxilla and enlargement of the bony orbits.3
The overall effects on the dimensions of an elderly human skull are a reduction in height and slight increase in width and depth.1
These skeletal changes cause gradual loss of support to the craniofacial soft tissue and changes in the distribution of subcutaneous adipose tissue leading to visible signs of ageing, such as a deepening of the nasolabial folds, sinking of the eyelids and hollowing of the temples.4
In terms of facial soft tissue, there is significant prolapse in various regions with age, with a loss of volume due to the depletion of fat and decreased subcutaneous support from collagen and elastin. In the forehead and brow region, the orbital rim and zygomatic arch become more apparent, resulting in an excess of orbital and temporal skin.4 In youth, deep and superficial pads of temporal fat, as well as the overlying temporalis muscle provide support to the periorbital area and lateral brow.
Whilst changes to the bony framework of the face can’t be reversed by the aesthetic practitioner, loss of soft tissue volume to the face can be replaced
There is a loss of temporal fascia and significant reduction in volume to the area, with the temporal fossa becoming increasingly more apparent and concave.4 A secondary effect is the loss of support to the eyebrows and a descent of any remaining soft tissue, leading to brow ptosis.4 The lateral brow lowers and flattens, and this is augmented by the drooping of the eyelids and the formation of forehead rhytides.1
Many patients overlook the loss of volume at the temples and change in the shape of the face, initially seeking treatment for major frown lines such as the nasolabial fold and forehead rhytides. However, the distribution of facial fatty tissue is one of the main indicators of age so, in order to regain a youthful appearance, it is essential to restore the fullness.1 Whilst changes to the bony framework of the face can’t be reversed by the aesthetic practitioner, loss of soft tissue volume to the face can be replaced. Treating the hollowing of the temples by revolumising the area with dermal fillers gives a more youthful look and has the secondary effect of lifting the lateral brow.
Dermal fillers provide an instant, minimally invasive and effective reversal of temporal volume loss. Whilst traditional human and bovine collagen fillers are used to fill fine lines, treatment of temporal volume loss is best carried out using hyaluronic acid (HA) fillers, such as Juvéderm, Belotero and Emervel. Collagen fillers are light and nonviscous fluids at room temperature and, if they come from bovine sources, can cause immunogenic reactions.5
HA fillers on the other hand possess ‘dynamic viscosity’, with viscosity altering under different levels of pressure.
During injection, HA fillers maintain a steady fluidity but once inserted they lose viscosity, making them stable and unlikely to migrate.5 This type of filler is ideal for treating the temples, with little or no migration, and immediate rejuvenation. It is better to under-correct the region with HA filler and assess the results before deciding if further treatment is required, rather than risking over-correction.
An alternative to HA fillers is the use of active fillers, which act as stimulators of collagen production by increasing inherent fibroblast activity. Microspheres of poly-Llactic-acid (PLLA) found in fillers such as Sculptra, which is the only FDA-approved filler of this kind,6 can be implanted at the temples to gradually fill the space created by the loss of temporal fat and fascia.
Using PLLA to treat the temples usually involves two to four treatments; with patients revisiting six to eight weeks post treatment. When using collagen stimulators, patients must be advised to massage the area of treatment daily to smooth the collagen and prevent the formation of nodules. From our experience, by the eighth week, the patient should see at least 20% of the total correction required. Whilst HA fillers provide instant rejuvenation and last about 12 to 18 months, use of PLLA microspheres takes eight to 10 months to reach the final desired effect, however this treatment has the benefit of lasting several years.5 Another option is calcium hydroxyapatite fillers, which act as conventional fillers after injection, causing instant smoothing of lines in the area. After several months, however, the micro-particles begin to stimulate production of collagen to restore volume in the area, amplifying and prolonging the rejuvenated effect for up to two years.5 Whilst HA fillers act as temporary solutions, collagen-stimulators are seen as a more permanent treatment as the effects are apparent for at least two years.5
In terms of patient satisfaction, it is essential to manage and agree on the reality of expectations. Each individual ages uniquely, so it is important to assess the facial anatomy and extent of volume loss, and to discuss the benefits, as well as limitations of using different fillers. The practitioner should educate the patient in what can realistically be achieved, with photographs taken before and after treatment. Many patients first recognise a prolapse of facial soft tissue with the deepening of laughter lines and periorbital wrinkles. Treating the nasolabial folds without addressing temple hollowing can create the appearance of puffy cheeks and distort the shape of the face. The patient should be informed that restoring the correct distribution of volume to the face provides the visual perception of youth. Although the volume can be restored in significantly sunken temples with filler, there may be an excess of redundant skin, which requires secondary measures or surgical intervention in order to fully rejuvenate the region. The patient should be made aware of this during consultation. The aesthetic practitioner also has a responsibility to provide the most cost-efficient treatment. Whilst soft tissue fillers could be applied to fully occupy temple depressions, this would not be an economic use of filler. With this region in particular, filler can be applied as pillars to act as ‘tent-poles’ in order to strategically lift the area (Figure 1) with the same effect as filling the entire cavity but at a fraction of the cost. With use of collagen-stimulators, the practitioner must bear in mind that there will be a gradual expansion to fill the space; overfilling the area can add to the risk of nodule formation.7
When treating the temples with HA or calcium hydroxyapatite fillers, it is also important to inject the filler deep enough to avoid the development of small subcutaneous nodules.7
The anatomic difference in the thickness of the dermis at different regions of the face must be considered. In the temporal and periorbital region in general, there is a reduction in dermal thickness, and in this region a light filler of small particle size is appropriate. The lower viscosity of small particle fillers yields a better result in areas of reduced dermal thickness.5
Whilst dermal fillers are minimally invasive and adverse reactions are rare, the patient must be fully informed of these risks nonetheless and the practitioner should be able to carry out appropriate action in these events. The patient should be advised to carry out gentle and regular massage post treatment, especially if they have been treated with PLLA-filler, to avoid nodules and encourage uniform distribution. Whilst certain nodules can be punctured and drained, such as the small white nodules formed from superficially injected calcium hydroxyapatite fillers, deeper nodules formed from lack of massage of PLLA fillers are difficult to reverse.7
In cases of overcorrection using HA filler or development of nodules, hyaluronidase can be used to dissolve the filler.3
A small amount of bruising or swelling can be expected with injecting the thin dermis of the temples, particularly in older patients, and persistent swelling can usually be managed with antihistamines.8
With treatment of the temples the most severe risk is injection of filler into the optic circulatory system, which can cause retinal occlusion and potentially blindness.8
The close proximity of distal branches of the ophthalmic artery to the site of injection can lead to perforation of one of these arteries (Figure 2). The systolic pressure within these arteries can cause any displaced filler to travel to the retinal artery causing blockage, blurred vision and complete loss of sight.8
To reduce the risk of arterial blockage, the practitioner should use small volumes of filler in order to avoid the arterial network of the temple, filler should be injected at the level of the temporal periosteum.8
Correct injection technique is key to a successful outcome, with permanent filler generally injected deeply into the temple depression, allowing room for innate collagen production and temporary filler injected at a more superficial level in strategic pillars to lift the area. Since the eyes and brows are key aesthetic features, and both are affected by temporal hollowing, revolumising the temples has a dramatic rejuvenating effect on the face.
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