Published online: 2020-05-22

Original Research

“Not Above, Not Below: Right in the Middle!”—

Novel Filler Technique for Temporal
Augmentation and Rejuvenation
Jason E. Cohn, DO1 Tyler Pion, BS2 Timothy M. Greco, MD, FACS3,4

1 Division of Facial Plastic Reconstructive Surgery, Department of Address for correspondence Jason E. Cohn, DO, Department of
Otolaryngology-Head and Neck Surgery, Philadelphia College of Otolaryngology—Head and Neck Surgery, Philadelphia College of
Osteopathic Medicine, Philadelphia, Pennsylvania Osteopathic Medicine, 4190 City Line Avenue, Philadelphia, PA 19131-
2 Philadelphia College of Osteopathic Medicine, Philadelphia, 1694 (e-mail: jasoncoh@pcom.edu).
Pennsylvania
3 Division of Facial Plastic Surgery, Department of
Otorhinolaryngology, University of Pennsylvania Perelman School of
Medicine, Philadelphia, Pennsylvania
4 Director, Center of Excellence in Facial Cosmetic Surgery, Bala
Cynwyd, Pennsylvania

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Abstract The temporal region is challenging to treat due to its thin skin, which has the propensity
toward showing irregularities. The literature on temporal hollowing augmentation
suggests placing the filler either into the subcutaneous space or within the temporalis
muscle. However, these techniques have been based upon opinion rather than
supporting anatomical and clinical data. We introduce a novel injection technique
to avoid complications and achieve lasting results. This novel technique was confirmed
with a cadaver model, in vivo model, and application to a human subject. The
anatomical layers of the temporal region were highlighted: the skin, subcutaneous
Keywords tissue, temporoparietal fascia (superficial temporal fascia), deep temporal fascia,
► temporal superficial temporal fat pad, and temporalis muscle. Particular emphasis was placed
augmentation on identifying the frontal branch of the superficial temporal artery to avoid vascular
► relevant anatomy complications. We believe the potential space between the temporoparietal fascia and
► injection technique the deep temporalis fascia is the safest, most efficacious plane to inject the temporal
► temporal hollowing region with a 27-gauge cannula. Our future goal is to recruit and present a larger series
► temporal filler of patients receiving this injection.

Practitioners often focus on the central two-thirds of the face
rather than the lateral one-third, leaving the temporal region
neglected.1 The youthful face is characterized by a smooth,
convex contour of the temples in which the anterior bony
margin of the skull is concealed. With aging, the superior part
of the face becomes more concave, and the bony margins of
the zygomatic arch, the temporal line, and the lateral orbital
rim appear more prominent, which leads to a sunken con-
tour and gaunt appearance of the temporal region. This is
primarily due to atrophy of the temporalis muscle and the
superior portion of the lateral temporal cheek fat pad with
aging. Therefore, the demand for aesthetic correction of
temporal hollowing has grown rapidly.2
The literature on temporal hollowing augmentation sug-
gests placing the filler into the subcutaneous space or within
the temporalis muscle through multiple entry sites.2 Others
have advocated deeper, supraperiosteal injections. In these
situations, a larger amount of filler is needed to transmit the
effect superficially.3 These techniques have been based upon
opinion rather than supporting anatomical and clinical
data.2 Therefore, we introduce a novel injection technique
to avoid complications and achieve lasting results.

Issue Theme Asian Perspectives on Copyright © by Thieme Medical DOI https://doi.org/

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Temporal Augmentation and Rejuvenation Cohn et al.
Methods
Two cadaver heads were obtained from Penn State College of
Medicine (Hershey, PA) on December 11th, 2018. Each
cadaver was injected bilaterally with 1 mL of hyaluronic
acid filler dyed with methylene blue to identify it during
dissection. Following injection, the two cadaver heads (four
temples) were dissected to demonstrate the relevant anato-
my and target injection area. This dissection was conducted
in the gross anatomy laboratory at the Philadelphia College of
Osteopathic Medicine, Philadelphia, PA.
Additionally, the anatomy of the temporal region was
recorded during a deep-plane facelift. A still image from
this procedure was obtained to demonstrate an in vivo model
of the relevant anatomy and injection technique. Finally, a
human subject was successfully and safely treated with this
novel technique. The human subjects in this study have
provided both verbal and written consent for images used
in the publication.
Results
Injection Technique
The first step of the injection is infiltration of a small amount
(approximately 0.1 mL) of 1% lidocaine with epinephrine. Next
is the creation of an entry point with a 25-gauge needle
15 degrees from the horizontal to the level of the deep
temporal fascia, where resistance will be encountered by the
tip of the needle (►Fig. 1A). A 27-gauge 1.5-inch cannula is
then introduced with a syringe containing a filler of choice
(►Fig. 1B). Using both visual and tactile feedback, the cannula
is advanced in a potential space between the temporoparietal
fascia and the deep temporal fascia. Prior to injecting, we
recommend rotating the patient’s head away while spreading
the overlying skin to reveal superficial vessels that the cannula
will pass beneath. At this time, one can palpate the frontal
branch of the superficial temporal artery at the level superior
or inferior to the horizontal line of the superior orbital rim
running toward the midline of the face above the brow.4 The
treating practitioner should ensure proper illumination and
magnification to achieve the desired result. Once injected, the
cannula is quickly fanned throughout the temporal region to
evenly distribute the product throughout the potential space
needing volume. The treating practitioner can analyze the
Fig. 1 Creation of entry point with 25-gauge hypodermic needle (A), followed by the introduction of a 27-gauge, 1.5-inch cannula (B) for temporal injection.
Brow posture can be addressed by marking a tangent line 1 cm superior along the temporal ridge and 1 cm parallel to the brow (C).
Facial Plastic Surgery
result by placing the backend of a cotton tip applicator to
appreciate the disappearance of the concavity that was present
prior to the injection. One should also mark out a specific
region to improve the aesthetic posture and anterior projec-
tion of the brow; a tangent line marked 1 cm superior along the
temporal ridge and 1 cm parallel to the brow (►Fig. 1C). We
recommend 1 to 2 mL of filler in each temporal fossa depend-
ing on the severity of the defect.
Cadaveric Dissection
In the cadavers, hyaluronic acid filler dyed with methylene
blue was injected bilaterally using the aforementioned tech-
nique. The skin was then incised and reflected to demon-
strate the corresponding anatomical tissue layers. First, the
subcutaneous tissue was identified. Deep to this layer was
the temporoparietal fascia (superficial temporal fascia). The
next layer was the deep temporal fascia overlying the
temporalis muscle. Once all of the layers were identified,
the relevant anatomy and proper filler placement location
were labeled with corresponding markers (►Fig. 2). It is
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paramount to note how the frontal branch of superficial
temporal artery is superficial to the dyed filler, and therefore,
protected from injury. As a result, we propose a novel target
plane for cannula placement of filler for temporal atrophy:
the potential space between the temporoparietal fascia and
the deep temporal fascia.
In Vivo Dissection
During a deep-plane facelift performed by the senior author (T.
M.G.), a temporal incision was made through the skin and
subcutaneous tissue. The aforementioned dissection was per-
formed, isolating the temporoparietal fascia and deep tempo-
ral fascia. In the subcutaneous plane, the frontal branch of the
superficial temporal artery was found crossing superficial to
the temporoparietal fascia. The backend of a scalpel handle
was used to develop a plane between the temporoparietal
fascia and the deep temporal fascia. A 27-gauge 1.5-inch
cannula was then placed between these two layers to demon-
strate the proper plane for this injection technique (►Fig. 3).
Clinical Patient
We also present the application of this novel injection
technique in a human subject. A 45-year-old female pre-
sented with the concern of a concave appearance to her
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Fig. 2 Cadaver dissection post injection of dyed filler to the temporal region: subcutaneous tissue (metal pin); temporoparietal fascia (orange
pin); deep temporal fascia (blue pin); frontal branch of superficial temporal artery (pink needle with the course of the artery outlined in black); target
plane for cannula placement of filler for temporal atrophy (probe: potential space between the temporoparietal fascia and the deep temporal
fascia). Notice how the frontal branch of superficial temporal artery is superficial to the blue filler, therefore, protected from injury.

bilateral temporal region. On exam, she was noted to have
significant bitemporal hollowing. In addition, the tail of the
brow disappeared around the lateral orbital rim (►Fig. 4A).
Two mL of viscous vycross hyaluronic acid filler (Juvéderm
Voluma, Allergan) was injected into the temporal region
bilaterally, using the aforementioned technique. The treat-
ment was well-tolerated without significant pain (rated by
the patient 1/10), bleeding, or bruising. Post injection,
marked improvement of temporal contour as well as brow
shape and position were appreciated (►Fig. 4B). She contin-
ued to follow-up for other services and her temporal result
was noted to last for approximately 1 year. It should be noted
that the use of Juvéderm Voluma in this patient was off-label.
Discussion
Many treatments for temporal hollowing have been suggested
including fillers, fat grafts/injections, and implants.5 The tem-
poral region is challenging to treat due to its thin skin, which
has the propensity toward showing irregularities.6
The anatomical layers of the temporal region include skin,
subcutaneous adipose tissue, superficial muscular aponeu-
rotic system, superficial temporal fascia, deep temporal
fascia, superficial temporal fat pad, and temporalis muscle.7
Several important structures pass through these regions,
making it a high-risk treatment area. These structures in-
clude the muscles of mastication, emissary and diploic veins
of the skull, perforators of the middle temporal vein, the
sentinel vein, the frontal branch of the superficial temporal
artery, and the temporal branch of the facial nerve.2,8
The superficial temporal artery lies in the temporopar-
ietal fascia. As it approaches the lateral border of the fronta-
lis, just above the brow peak, it becomes more superficial in
the subcutaneous plane. The middle temporal vein runs
approximately 2 cm above and parallel to the zygomatic
arch between the superficial and deep layers of the deep
temporal fascia.3,7 This vessel is particularly at risk during
injection due to its relatively large caliber (2 mm). One of its
tributaries, the sentinel vein, lies lateral to the lateral orbital
rim and passes from the subcutaneous layer through a
perforation into the middle temporal vein. Therefore, this
vessel is also at risk during injections.7
Therefore, deep injections are advocated within a finger-
breadth of the arch or at least several centimeters above it. In
addition, the frontal branch of the artery can still be injured if
it is lacerated by a needle going from superficial to deep. The
injection needle should be constantly moving with antero-
grade and retrograde injections to displace vasculature and
minimize intravascular trauma. The use of a cannula can
lessen the risk of vessel puncture. Turning the patient’s head

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Fig. 3 Dissection of the temporal region during a facelift, identifying the skin, subcutaneous tissue (skin hook), and the target plane for filler
injection (cannula) between the temporoparietal fascia (TPF) and deep temporal fascia (DTF). Notice how the frontal branch of superficial
temporal artery (looped with suture) is located in the subcutaneous tissue immediately superficial to the temporoparietal fascia.

Fig. 4 A 45-year-old female with significant bitemporal hollowing preinjection (A) with marked improvement postinjection (B).

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medially and spreading the overlying skin can also assist the
treating practitioner by revealing superficial veins.3
A feared complication of filler injections in the temporal
region is vascular occlusion with resultant necrosis. This
complication has been associated with injections placed
superficially or into the deep tissues.8 The area can be
massaged to promote migration of the material or if hyalur-
onic acid filler was injected, hyaluronidase can be used as a
reversal agent.3,8 If there is no resolution, this can lead to
necrosis of the superficial dermis with scarring.8 The most
feared complication associated with treating the temporal
region is blindness through occlusion of the retinal artery. To
prevent this, deep supraperiosteal injections in contact with
the bone are recommended. However, the temporal region is
a point of convergence for the sutures of the frontal, sphe-
noid, parietal, and temporal bones. Therefore, there are areas
of bone instability where intracranial penetration can occur.9
Conclusion
Currently, there is no consensus for the proper injection for
temporal augmentation. Therefore, we introduce our novel
technique which allows for longevity of effect while avoiding
the aforementioned complications. We believe the potential
space between the temporoparietal fascia and the deep tem-
poralis fascia is the safest, most efficacious plane to inject the
temporal region with a 27-gauge cannula. This is evidenced by
both basic science cadaveric dissection as well as application to
a human patient. Our future goal is to recruit and present a
larger series of patients receiving this injection.
Temporal Augmentation and Rejuvenation Cohn et al.
Conflicts of Interest
None.
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