Entre os procedimentos e as técnicas que potencializam a beleza da região dos olhos, está o preenchimento de supercílios e têmporas. Além de repor o volume, o preenchimento traz jovilidade ao rosto e o resultado é excelente.
Quando envelhecemos, as estruturas que dão sustentação à face (colágeno, compartimentos de gordura, músculos e ossos) vão sendo reabsorvidas pouco a pouco, fazendo com que o aspecto jovem se perca gradativamente. Algumas pessoas podem apresentar um afundamento na região das têmporas (entre o final da sobrancelha e a parte lateral do couro cabeludo), o que acaba causando um aspecto envelhecido ao rosto.
Uma solução para recuperar a harmonia da face repondo o volume desta região com resultado imediato e efeito natural é o preenchimento dos supercílios e têmporas com ácido hialurônico ou bioestimuladores de colágeno.
O preenchimento dos supercílios e têmporas é um recurso muito eficaz para repor o volume que foi absorvido com o passar dos anos nessa região. A aplicação do preenchedor é realizada em consultório médico, o procedimento é rápido e não há necessidade de cirurgia ou de repouso, podendo o paciente retornar imediatamente às suas atividades. O resultado é surpreendente e natural: a harmonização da face.
O que é o preenchimento de supercílios e têmporas?
É um procedimento que consiste em preencher os supercílios e têmporas, região que perde um pouco de volume e gordura com o passar dos anos.
A título de curiosidade, as têmporas se localizam nas laterais da cabeça, próximas aos olhos e acima dos ossos da bochecha (malares). Na medida em que envelhecemos, essa região pode se tornar mais “funda” devido a uma série de fatores. São alguns deles:
- Perda de gordura e volume;
- Reabsorção do osso temporal;
- Hipotrofia dos músculos dessa região.
Para quais os tipos de paciente esse procedimento é recomendado?
Esse tratamento é recomendado para pacientes com falta de volume nessa região, com leve rebaixamento na cauda do supercílio, ou para aqueles com aspecto de olhos fundos, com o sulco profundo, com o objetivo de amenizar o aspecto esqueletizado dos olhos.
Como é realizado o preenchimento de supercílios e têmporas?
O preenchimento é realizado por meio de aplicação de preenchedores, ácido hialurônico ou bioestimuladores de colágeno, por meio de cânulas ou agulhas, modelando dessa forma essa região, preenchendo as depressões que surgem com a idade ou emagrecimento importante.
Quais as particularidades deste preenchimento?
Em geral esta região demanda bastante volume de preenchedor. Espere gastar pelo menos 1 seringa em cada lado, para conseguir um bom resultado estético.
Como em todo tratamento estético, o segredo do sucesso passa pela escolha do profissional que vai planeja e executar o procedimento.
Cuidados importantes pós-preenchimento temporal
Leia com atenção e siga as orientações para que o resultado seja conforme o esperado:
- Não faça atividades físicas por pelo menos 24h para evitar problemas como a formação de hematomas ou edemas em excesso;
- Evite ao máximo a exposição ao sol, pois os raios solares favorecem o surgimento de manchas nos pontos avermelhados ou arroxeados da pele. Tanto o calor como o frio em excesso podem interferir no processo de absorção do edema e manter o rosto inchado por mais tempo;
- Não massageie o local da aplicação por pelo menos 6 horas depois de feito o procedimento. Isso inclui o uso de cremes de limpeza, protetor solar e maquiagem;
- Passada às 6 horas após o procedimento, é importantíssimo o uso diário do filtro solar;
- Depois do período de repouso, é importante investir em atividades físicas, pois a prática regular de exercícios retarda o envelhecimento;
- Ter uma alimentação saudável, rica em alimentos com colágeno, é essencial para manter os resultados do tratamento. Evite consumir açúcar, pois esse alimento contribui para o aparecimento de rugas. O cigarro é outro hábito nocivo que deve ser eliminado de sua vida.
- Não adianta fazer o preenchimento, investir em cremes e serums caros e manter uma rotina de hábitos nada saudáveis.
- Lembre-se de comparecer ao retorno, é de grande importância para que eu possa avaliar como está evoluindo seu tratamento.
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Temporal Fossa Atrophy in Aesthetic Medicine: Anatomy, Classification, and Treatment
Francesco Idone, MD, Elisa Bolletta, MD, Andrea Piedimonte, MD, and Ferdinando Paternostro, MD
Summary:
Hyaluronic acid fillers indisputably represent an important tool for face rejuvenation and volume restoration. The temporal area has recently been considered as a potential site of injection. As it happens in the middle face and in other regions of the face, the temporal fossa changes according to the aging process. In a young person, the temple profile has a fullness aspect, and this contributes to giving the face a beautiful and healthy appearance. With age, the loss of volume leads the bone prominences to be visible. The aim of this article is to classify the temporal fossa atrophy and get better into the anatomy, identifying the ideal plane to inject in, through the use of a safe and reliable technique. Cadaver dissections have been performed to specifically describe the anatomy of the temple layer by layer. The authors’ preferred technique, called interfascial by cannula implantation, is discussed. All the treated patients reported a good improvement by survey according to the Global Aesthetic Improvement Scale scale. No major complications were detected. No ecchymosis neither swelling were documented. Although further studies are necessary to broaden the casuistry and better verify the potentiality of this technique, the authors do believe that it could be considered a very reliable procedure with pretty consistent results, if supported by an adequate and imperative anatomical knowledge.
INTRODUCTION
The fullness of the temporal area is considered a sign of youth and health. As the aging process passes, the temporal fossa tends to lose its typical convex appearance and turns into a depressed area. As a result, the temporal crest and the zygomatic arch become visible, conferring a skeletal aspect to the face.
According to the clinical study of hundreds of patients, 3 grades of temporal atrophy were described, taking into account the relation between the tissues of the temple and the eyebrow tail. Grade 1 indicates an initial change of the shape in the temporal area, which becomes flatter even without the presence of an hollow. In grade 2, an hollow starts to appear, with a distance between 0 and 3 mm from the most depressed point of the temporal fossa to the tangent line passing through the tail of the eyebrow. In grade 3, the concavity is further evident with a discrepancy of more than 3 mm between these landmarks (Fig.1).
Fig. 1.
Classification of the temporal fossa atrophy based on volume loss, measuring the distance between the most depressed point of the temporal fossa (blue dot) and the tangent line passing through the eyebrow tail (blue line). Grade 1: no distance between the blue line and the blue dot is detected. Grade 2: concave aspect of the temple with a 0–3 distance between the blue line and the blue dot. Grade 3: concavity with a distance between the blue line and the blue dot wider than 3 mm.
METHODS
Six fresh-cadaver specimens were dissected to better understand the anatomy of the temporal fossa and to find out an ideal plane of hyaluronic acid (HA) implantation. Proceeding from the skin to the deep layers, 11 layers were identified: (I) skin; (II) subcutaneous fat; (III) superficial temporal fascia; (IV) deep fat; (V) superficial lamina of the deep temporal fascia; (VI) interlaminar fat; (VII) deep lamina of the deep temporal fascia; (VIII) temporal extension of the Bichat fat; (IX) temporalis muscle; (X) lateral pterygoid muscle; and (XI) periosteum.
From March 2017 to March 2020, 57 patients were treated. The author’s preferred plane of implantation was between the superficial and the deep temporal fascia (layer IV). The product used was a high cohesivity (2.6 N.s) hyaluronic acid with a high G’ (290 Pa).
In this article, the authors discuss their preferred technique, which consists of HA filler implantation between the superficial and the deep temporal fascia, named “Interfascial by Cannula Implantation” (ICI technique). Several authors have described the above plane as a potential plane for filler injections. Here, the fat and the loose areolar tissue are located in an avascular plane, in a space that was previously described as a smooth gliding plane.
The technique, in which the technical aspects of the described procedure is shown) involves the identification of the entry point just medial to the temporal crest, at least at 2 cm distance from the temporal ligamentous adhesion; a 25-G needle is used till it reaches the bone, and then a 25-G/5-mm cannula is inserted vertically down to the periosteum. Once the plane is achieved, the cannula is turned laterally to pierce the superior temporal septum and enters directly into the interfascial plane of the temporal fossa (between the superficial and the deep temporal fascia). The periosteum represents the continuation of the deep temporal fascia, whereas the frontalis muscle represents the continuation of the superficial temporal fascia. To ensure a safe entrance in the correct plane, it is advisable to move laterally after reaching the periosteum, using a technique much similar to the brow lift procedure. Once entered with the tip into the interfascial plane, a small quantitative of filler is injected; the absence of resistance confirms the correct plane depth. The product should always be injected slowly and steadily without a significant force.
Video 1.
Interfascial by Cannula Implantation. Video 1 from “New Perspectives In Temporal Fossa Atrophy: Anatomy, Classification, and Treatment in Aesthetic Medicine.”
RESULTS
A retrospective study was conducted on 50 patients (7 of them were excluded due to an incomplete photographic documentation). An estimated 35 of the treated patients were classified as grade 2, and 15 of them as grade 3. All the patients reported a high score of satisfaction according to the Global Aesthetic Improvement Scale scale evaluation. No major complications were detected. Neither ecchymosis nor swelling were documented.
In the grade 3 atrophy group, 2 of 15 patients reported a mild pain in the area of injection during the 48 hours post-treatment; yet no analgesics were required. The average amount of filler was 1.5 ml for grade 3 per side, and 1 ml for grade 2 per side. The median follow-up was 14 months and no touch-ups were needed.
DISCUSSION
Based on the anatomical dissections, fat compartments were found in 4 layers (II, IV, VI, and VIII). According to the literature, the nomenclature of these layers is pretty confusing because both the fat in layers II and VI is named “superficial,” and either the fat in layers IV or VIII is named “deep.”
Nonetheless, in our opinion, the use of the adjective “superficial” and “deep” should be solely reserved to layers II and IV because of their relation with the superficial fascia. “Interlaminar fat” is the name suggested for the fat of the layer VI, which is located between the superficial and the deep lamina of the deep temporal fascia. Finally, the last fat compartment (layer VIII) should be named retro-zygomatic, due to its anatomical relation with the zygomatic arch. As known, the temporal zone is fraught with vessels; therefore a precise knowledge of the whole vasculature should be acquired before injecting. In the literature, 3 potential planes for safe injection within the temporal fossa are described: subcutaneous, deep to the temporoparietal fascia, and below the temporalis muscle, on the periosteum.
Although some authors have not shown any vascular connection between the deep and the superficial temporal fascia, the presence of the medial zygomatico-temporal vein (sentinel vein) was constantly confirmed in all our dissected specimens. If the area close to the zygomatic bone needs to be filled, care should be taken to avoid damages to the medial zigomatic temporal vein, which seems to pierce the deep temporal fascia just behind the frontal-zygomatic suture or the zygomatic tubercle.
The vascular anatomy of the face is very complex. There are no safe areas. Yet, we are able to rely on safe planes. The interfascial plane (Fig.2) is a rather avascular area, previously used as a reference plane for the surgical brow lift or for head and neck reconstruction procedures. In the literature, it is often described as an excellent dissection plane; being it an avascular plane.
Fig. 2.
Anatomical view of the pretty avascular plane, which is the authors’ preferred injection site.
Attention should be paid to avoid injury of the sentinel vein or the frontal branch of the facial nerve, which stands in the context of the temporal fascia on the roof of the injection plane.
CONCLUSIONS
To the best of our knowledge, there are no studies related to the classification based on a volumetric evaluation of the temporal atrophy. In the present study, the presence of the lateral pterygoid muscle (Fig.3) was consistently found on the anteroinferior aspect of the temporal fossa in all the investigated cadavers.
Fig. 3.
The presence of the lateral pterygoid muscle on the anterior aspect of the temporal fossa. Our study is the first one in the literature to consider it as a part of the temporal area layers.
Although the lateral pterygoid muscle does not have an active role in the temporal atrophy process, the authors believe that it should be added to the traditional layer subdivision of the temporal fossa. Hence, a specific and accurate nomenclature is proposed to define the fat layers of the temporal fossa (layer II: superficial fat, layer IV: deep fat, layer VI: interlaminar fat, layer VIII: retro-zygomatic fat).
Although further studies are required to widen the analysis and to better verify the potentiality of the ICI technique, the authors believe that the ICI technique can be considered a reliable procedure with pretty consistent results, when supported by an adequate and mandatory anatomical knowledge. The plane of injection enables a natural reshaping of the temple with a low risk of complications, such as vascular or nerve injuries, surface irregularities, and product migration.
ACKNOWLEDGMENT
We sincerely thank the ICLO Cadaver Lab for the support provided for the dissections of the cadavers.
Footnotes
Published online 27 October 2020.
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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