Temporal volume loss is part of the natural aging process of the face. It is the result primarily of fat pad atrophy, but loss of bone, soft tissue, and muscle also contribute. Losing volume in the temples leads to:
- Lowering of the eyelid and eyebrow
- Skin laxity in the periorbital and cheek area
- Changes to the overall shape of the face
Probably the most significant of the above changes is #3. A youthful face is “upside down egg” or “heart” shaped. The upper face is rounded, with the widest part being the upper cheeks. The center of beauty is the eyes, and the youthful face emphasizes this. With the temple wasting associating with the aging face, the overall shape turns more square, and the lower face becomes dominant. Filling the temporal defect can help to re-establish the upper face dominance that is the hallmark of youth and beauty.
There are basically 2 ways to fill the temples. Filler can be placed deep to the temporalis muscle, at the level of the periostium of the bone in the temporal fossa. This type of correction will lift the muscle, fat, and soft tissue “en mass” for a very even appearance. Needles are needed for this technique because the temporal fascia is difficult to pierce with cannulas. This is the preferred method of the author. The second method is placement of the filler just below the dermis, in the subcutaneous tissue. Imperfections caused by uneven placement of the filler will be more visible because the tissue in this area is very thin. Bruising is more likely as well because there are multiple veins in this area. Using blunt cannulas helps to mitigate bruising but not eliminate it.
Risks associated with temporal fillers are similar to placement in all other areas: bleeding, bruising, infection, unevenness, unsatisfactory result, need for more filler, vascular compromise including necrosis AND BLINDNESS. Fortunately, blindness is an extremely rare complication of fillers with somewhere between 100 and 200 cases reported in the literature. The most common “filler” sighted for this complication is fat, but it has occurred with all the fillers. It is the duty of the injecting physician to take all precautions to minimize this catastrophic risk. The etiology of blindness is occlusion of the retinal artery by filler that is obstructing its blood flow. Filler makes it to this area because there are natural occurring anastomoses between the external (face) and the internal carotid (ophthalmic) systems. Techniques to minimize blindness are:
- Slow injection of the filler which prevents retrograde flow of filler
- Use of large cannulas or needles which makes entry into vessels more difficult. (Using cannulas has been shown to be significantly safer than needles because their blunt tip is less likely to result in an intravascular injection)
- Moving the end of the needle or cannula constantly to avoid a bolus injection within a vessel
- Aspiration prior to injection to see if there is a flash of blood, indicating a intravascular location
Sculptra is ideally suited for correcting the temple defects. When placed at the level of the periostium (the author’s preferred method), it creates a very long lasting correction (at least 2-3 years) formed by collagen and neo-osteogenesis. More importantly, it is the only filler in which aspiration can be relied upon to produce a flash. Sculptra is nearly the consistency of water and will flash with a red reflux of blood if intravascular. The viscosity of all the other fillers makes this technique an unreliable indicator for testing where the tip of the needle is. That makes Sculptra much safer for use in this area.
For improving temporal volume loss, Sculptra will produce a long acting and natural appearing correction with a safety profile that is superior to all other fillers on the US market.