Ayman El Attar, MD, ABLS, ABFM

Dr Ayman El Attar

Founder of Derma Laser Centers of New Jersey, USA

General Secretary of The American Academy of Aesthetic Medicine

Derma Laser Centers is a full spectrum Aesthetic practice, serving the US Northeastern tri-state area since 2002. Dr. El Attar is triple a board certified physician and surgeon by the American Board of Family Practice, the American Board of Laser Surgery, and the American Academy of Aesthetic Medicine. Dr. El Attar has taught aesthetic medicine and surgery in 18 countries on six continents.

He has dedicated the past ten years of his career to the art and science of Cosmetic and Laser Surgery. Dr. El Attar graduated from Alexandria Medical School with honors in 1987. He completed residencies in both General Surgery and Family Medicine, and obtained a Masters Degree of Surgery in 1992. He was Assistant Lecturer of Surgery at Alexandria University, and Visiting Instructor of Surgery at the Medical College of Ohio. He then finalized his Ph.D. thesis in 1998. He has several publications in the most reputable medical and surgical journals.

Besides being a senior Faculty and Secretary of the American Academy of Aesthetic Medicine, Dr. El-Attar is an active member of the American Society of Laser Medicine and Surgery, The American Academy of Cosmetic Surgery, the International Society of Hair Restoration Surgery and the American Academy of Hair Transplantation Surgery.

Unifocal Technique For Temporal Hollow Volume Augmentation with Hyaluronic Acid Fillers

Ayman El-Attar, MD, ABLS, ABFM

Abstract
Facial atrophy of bones, the subcutaneous tissue as well as the skin is one of the three major D hallmarks of aging: descent, deterioration, and deflation. Global approach to volume replacement is essential to create a natural, youthful appearance in facial aesthetics. The Temporal hollow wasting is a commonly over looked part in facial volume restoration practices using fillers.

Recent advancements, including more versatile hyaluronic acid facial fillers, refined new injection techniques, lack of need for anesthesia, and the adoption of longer blunt cannulas rather than the old sharp short needles, have contributed to improved patient outcome and reduction of complications and improve patient satisfaction with facial augmentation procedures.

In this paper we review our experience using unifocal technique for temporal hollow volume replacement in 10 patients with 3 ml of Hyaluronic acid on each side using 25G blunt cannula. The review includes technique, clinical outcome, and adverse effects.

Keywords: hyaluronic acid filler, blunt cannula, Temporal, hollow.

Introduction:

With explosion in the need for aesthetic services by a growing baby boomer population, the quest to defy facial aging is on the increase. Facial aging has three major mechanisms, mechanical, photoaging, and volume loss.

Mechanical aging of the face is caused by muscular contraction and gravitational traction on facial structures. Photo aging caused by decades of exposure to ultraviolet radiation that affect keratinocytes(1). Volume loss including skin, subcutaneous and bone resorption is an equally important far in the pathogenesis of the stigmata of aging. The aging process is further complicated by the natural decline of the hyaluronic acid levels after the age of 25 reaching about 50% by age 50 and only 10% by 70 years of age.

Multiple techniques have been developed to reverse these atrophic changes including fat transfer, and the use of facial synthetic fillers most commonly made of hyaluronic acid(2) (3). The consequence is an increasing emphasis on the use of volume restoration procedures to address the aging face even after traditional facelift procedures. This is known as 3D face-lifting.


Temporal fossa hollowness is a hallmark of aging. Loss of volume in the temple can result in a skeletonized, wasted appearance. In optimizing temporal hollow volume all levels of tissue loss has to be addressed beginning with the establishment of deep structural support.

Hyaluronic acid augmentation of the temples can counteract volume loss and achieve a more balanced and youthful appearance. Although the temporal fossa is a critical area for volume restoration of the aging face, published information is limited.

Anatomy:


For optimal outcomes, it is necessary for aesthetic physicians to have a thorough understanding of the anatomy of the temporal fossa. The temporal hollow is a narrow fan-shaped space that covers the lateral surface of the skull.
Boundaries of the fossa are skull bones medially. Laterally, the temporal fascia. Anteriorly the posterior surface of the frontal process of the zygomatic bone and the posterior surface of the zygomatic process of the frontal bone.while superiorly, pair of temporal lines (superior and inferior temporal lines) that arch across the skull from the zygomatic process of the frontal bone to the supramastoid crest of the temporal bone. Inferiorly the zygomatic arch laterally and by the infratemporal crest of the greater wing of the sphenoid medially.
The major structure occupying this fossa is the temporalis muscle. Other structures include deep temporal arteries, deep temporal nerves, the superficial temporal artery, and the zygomaticotemporal branches of the maxillary nerve.
While a proper injection technique is paramount, it is equally important to understand the aesthetic principles of beauty; the harmonious inter-relationship of features that constitute a balanced and attractive face. A youthful female face should be oval, loss of the temporal volume result in an illusion of wasted and aged face(4).


Volume loss assessment:
Most aesthetic clinicians incorporate some sort of assessment scale in their clinical practices at both the assessment and treatment levels. There is no single standardized, validated assessment scale. In this study we used Attar’s System for Facial Atrophy Classification shown above.

It is not uncommon to receive aging complaints focusing on deepening nasolabial folds rather than the responsible deepened temporal hollow that requires primary treatment to restore a youthful outlook. Patient education and selection is crucial to achieve desired natural rejuvenating results.

Study design and patients:

This is a prospective study of 12 patients, including 10 females and 2 males with grade IV facial atrophy. Patients sought facial rejuvenation and after consent underwent Hyaluronic acid injection for temporal fossa augmentation. Adverse effects were recorded. Patients were followed for a period of 12 months.

Technique:





Prior to the procedure patients are asked to stop medications and vitamins that may increase their chance for bruising for a period of ten days. Medical photographs are obtained in three views: frontal, oblique and lateral. These photographs are reviewed with the patients. Before and after photographs of other patients demonstrating the effects of temporal hollow restoration was shown to the patients. Informed consent was obtained.

The treatment area was disinfected with alcohol. Scribing of the area of deficit while patients are able to review the markings and critique it for their preference. Entry point at the lateral eye brows are anesthetized using 0.1ml of lidocaine 1% with 1:200,000 epinephrine. A 20 G sharp needle was used to create the entry point. There was no need for facial block or mixing the filler with lidocaine. All patients tolerated the procedure without anesthesia. The Hyaluronic acid 3ml syringe is attached firmly to the 22G included blunt cannula. The cannula was introduced at 45 degrees and directed superiorly and laterally deep to the temporal fascia. After aspiration, the filler is deposited in linear streaks and the cannula is rotated in fanning manner and the step is repeated until the temporal defect is filled. Ice packs applied and patients discharged with instructions to use ice 20 minutes three times per day for 48 hours.














Side effects and follow up:

Among the 12 patients treated in this series, there were one case of mild bruising and one case of headache that lasted 48 hours and responded to Tylenol therapy. No other adverse effects were noted. One year follow up showed a satisfactory longevity of the filer. Most patients requested repeat therapy to maintain their results.

Discussion:

Deep temporal hollow is a commonly overlooked sign of advanced facial aging by both patients and practitioners. Fillers made of hyaluronic acid are widely used for correction of aging induced facial deflation(5). Optimal results in temporal hollow volume restoration and contouring depend on correcting deficiencies at various layers of the fossa. This includes creating a foundation for deep structural support in the supraperiosteal or submuscular plane; using hyaluronic acid. While volume repletion of subcutaneous fat compartment was performed using more cross-linked hyaluronic acid. Additional fine refinements were performed using less cross-linked hyaluronic acid at dermal and subdermal level.

Ideal soft tissue filler should also provide an optimal balance of longevity, lifting capacity and ease of injection (6). In our experience the hyaluronic acid was found to have this favorable blend of physical properties, making it well suited to rebuild the temporal hollow. Other advantages with hyaluronic acid filler are its consistent predictability and reversibility with hyaluronidase, its intermediate duration, natural looking correction of the defect. Other advantages include minimal patient discomfort and downtime.

Conclusion:

Although temporal hollow is a significant manifestation of aging, it is still currently undertreated. Both physicians and patients will come to appreciate the dramatic improvement that can be achieved by restoring volume in the temporal hollow and that this practice will come to be incorporated as a mainstay of global facial rejuvenation.

The Unifocal approach for temporal hollow augmentation with hyaluronic acid using 25G blunt cannula allows painless instant correction of this defect, with high patient satisfaction and minimal complications.


References

1. Coleman SR, Grover R. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthet Surg J. 2006;26(1S):S4–S9. [PubMed]
   
   
2. Jones D, Flynn TC. Hyaluronic acids: clinical applications. In: Jones D, editor. Injectable Fillers: Principles and Practice. Oxford: Wiley–Blackwell; 2010. pp. 158–174.
   
   
3. Raspaldo H. Volumizing effect of a new hyaluronic acid sub–dermal facial filler: a retrospective analysis based on 102 cases. J Cosmet Laser Ther. 2008;10(3):134–142. [PubMed]
   
   
4. James J, Carruthers A, Carruthers J. HIV–associated facial lipoatrophy. Dermatol Surg.2002;N;28(11):979–986. [PubMed]
   
   
5. Solish N, Beer K. Hyaluronic acids: basic science. In: Jones D, editor. Injectable Fillers: Principles and Practice. Oxford: Wiley–Blackwell; 2010. pp. 19–26.
   
   
6. Tezel A, Fredrickson GH. The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther.2008;10(1):35–42. [PubMed]