Examples of Treatment Areas

Temporal Hollow Augmentation

Numerous structural changes are brought on by the intricate biological process of facial ageing and are regulated by a complex synergy of skin texture changes, bone resorption, soft tissue atrophy, gravity, and other factors. The temporal region is one of the most crucial and essential components of the upper face, but both patients and practitioners frequently ignore, underappreciate, and neglect this area. Patients frequently report themselves as looking haggard, withered, or skeletonized as a result of volume loss in the temporal region of the face.

Therefore, when doing a global assessment of the face for volume loss, consideration should be given to temporal volume restoration after careful investigation. Due to serious problems that have been documented in the literature, this procedure’s safety is still being investigated Many medical professionals believe that injecting in the temporal region is a high-risk treatment and that the temple is “treacherous territory.” Undoubtedly under reported are severe cases of iatrogenic blindness and vascular occlusion following dermal fillers.

Anatomy and physiology of the temporal region

Increase safety when injecting in this area, practitioners must have a thorough awareness of the link between the temple structures and the temporal fossa’s limits. To comprehend and appreciate the minuscule depths between each layer, practitioners need to place tissue planes in the temporal region into context. The zygomatic arch is below the level of the temporal fossa, which is a shallow dip on the side of the skull bordered by the temporal lines. The layers of skin are followed by subcutaneous fat, which is weakly adhering to the superficial temporoparietal fascia (STPF), which houses the temporal branch of the face nerve as well as the superficial temporal artery.

With a sharp needle, this is a dangerous place to be. The deep temporoparietal fascia (DTPF), the deep temporal artery, the large temporalis muscle, and the pericranium and bone all come after loose areolar tissue that comes before the temporalis muscle fascia and the middle temporal artery. The injector must consider several factors as the needle or cannula goes through each of these zones.

Product selection

Belotero® Volume with Lidocaine, which is a HA-based gel, completely homogenous with low viscosity but high cohesivity and elasticity and moreover, reversible. Loss of temporal support to the lateral brow, coupled with loss of fullness in the upper eyelid, create the impression of brow ptosis, with the eyebrow seemingly descending to a position at or below the superior orbital rim. The technique involves restoration of temple harmony and balance with injection of the superior aspect of the temple with a concomitant lift of the lateral brow.

Cannula

The use of a blunt cannula to treat the temporal region is becoming more popular right now. The advantage of using a cannula for injections is the lower chance of an intravascular incident when working at a shallower depth. Additionally, a concavity correction could be accomplished with less product. The STPF is rather sturdy despite being relatively thin (it is a structure unlikely to be penetrated accidentally), and it takes a lot of force to break through the tissue. Some practitioners favour massaging the STPF after injecting a substance onto it to generate a smooth surface. To prevent the development of uneven contours when working at this level, product selection is essential. Understanding the superficial temporal artery and vein is essential.

At this depth, the middle temporal vessels must be respected. Caution is usually suggested due to the possibility of considerable anatomical abnormalities in the temporal vessels’ course. Before finishing the restoration with cannula work in the more superficial planes, placement of product deeper in the fossa may be necessary if the concavity is substantial. The concavity should typically be addressed, although the development of convexity may give a negative and rather masculine feature. Temporal wasting depression in the female face typically does not require a complete repair. Consequently, the natural feminine facial silhouette is disturbed.

Supraperiosteal small bolus injection technique to the superior temple

Anatomically there is no physical barrier present sub-muscularly at the inferior boundary of the temporal fossa and similarly under the DTPF. These results suggest that if injections are administered deep sub muscularly, there may be a chance for inferior product migration into the pre-masseteric area beneath the zygomatic arch. However, product migration is becoming less common because to the cohesivity of the current generation HA solutions that are now accessible. Injecting into the deep cavity of the temporal fossa’s central depression, where a needle would encounter multiple dangerous landmarks, is the justification for using a superior temporal approach (as described previously in the article). Leading specialists in the field have recently explored how injecting more precisely can lower the probability of the embolic phenomena.

The procedure

The frontalis muscle and the temporalis muscle are divided by the temporal fusion lines, which are a visible and felt zone of fixation. Marking the temporal fusion line 1 cm above the forehead and 1 cm laterally to this point can help you find the proper location for the superior temporal injection. This injection technique has extremely little depth, and the needle’s tip will nearly immediately feel bone. Contrarily, injecting into the temporal fossa’s central depression feels quite different because the needle is moving through a much deeper region. According to many medical professionals, it is safe to inject when a needle meets bone. However, the author advises always aiming high.

In order to minimise hazards, practitioners have a duty of care to their patients. To stop the injected substance from tracking laterally, a shielding finger is positioned anterior to the hairline. Instead, then injecting directly into the hollow, superior temple injections allow the dermal filler to flood into the tissue below and fill the cavity from above. At this initial meeting, the author prefers to inject no more than 0.5ml bilaterally since she feels that using a sessional approach is a safer course of action. The evidence for injecting tiny aliquots of 0.1 millilitres at each injection site and rerouting the needle without changing its course is growing.

Favourable with prompt intervention than if a huge bolus of product was injected, resulting in an embolic event. According to experts’ recommendations, smaller bolus injections performed under moderate pressure and with the least amount of drug released are safer than bigger ones. Following these suggestions could prevent a significant vascular impairment.

Serious complications

There is now heightened awareness of the possibility of iatrogenic blindness following facial cosmetic injections. The literature describes around 60 cases globally. It is highly probable that this number will continue to increase.

The risk of iatrogenic blindness following facial cosmetic injections is now more widely recognised. There are descriptions of 60 cases worldwide in the literature. There is a strong likelihood that this number will keep rising.

The pain associated with BoNT-ONA injections for palmar and plantar hyperhidrosis can deter patients from undergoing the procedure. Due to the rich nerve endings in the palms and soles, pain can be significant with the numerous injections needed to achieve the desired effect. To reduce discomfort from the injection, several anaesthetic methods have been reported, including oral and intravenous sedation, topical lidocaine cream, nerve blocks, and cryoanalgesia (ice block). Radial and ulnar nerve blocks, when administered properly, are very effective in minimising pain and are commonly utilised prior to injection.

For patients who are more sensitive to pain or are wary of the pain associated with the injection, topical 2.5% lidocaine cream is applied 30 to 60 minutes prior to the procedure. Some physicians use vibration in conjunction with ice packs to reduce pain sensation. It is believed that the stimulation of vibration receptors inhibits the interneurons that transmit the pain signal. Vibration can be administered with a handheld massager or other similar device.

Define the injection field as a grid on the palm and sole. Once the field of injection is defined, a total of 100 U per palm of BoNT is injected with a 26- or 30- gauge needle and a TB syringe. The BoNT is diluted in 3 to 4 ml of normal saline and then sub-dermally injected into each 1- cm square area of the palm and three sites in each digit. After the procedure, ice packs are applied for 15 minutes to confirm no immediate reaction to the toxin.

Post-treatment Care

Patients are monitored in the clinic for signs and symptoms of adverse events (AE) and encouraged to report any AE that occur following treatments and between follow-up visits. Patients are routinely advised to attend for a review in 2-4 weeks to check the treatment outcome. Patients are advised to self-refer for repeat treatment once their symptoms begin to return.

Patient Satisfaction

Patients who have undergone BTX-A injections claim a significant decrease in excess sweat production and improvement in quality of life.

Disadvantages

The primary disadvantage to treating hyperhidrosis with botulinum toxin is its temporary improvement. Although there may be an attenuation effect, anhidrosis typically lasts six to nine months, and thus repeated injections are required. It is noted that patients who have had more than four treatments tend to return more frequently for subsequent injections. We speculate that this occurs because patients are less tolerant of symptoms once they become accustomed to the anhidrosis. However, research suggests that some patients may develop antibodies to the toxin, leading to reduced treatment efficacy.