October 16, 2023

Dr Tim eye injection anatomy

Recently there have been some interesting case studies reported in the field of aesthetic medicine citing a complication of alopecia after temple lifting techniques with dermal filler. highlighted in a 2023-published clinical paper by Dr Marina Landau et al.

In this blog, Dr Tim Pearce highlights the details of the published paper following cases of alopecia or hair loss after temple filler in otherwise healthy patients, discussing the factors that led to the alopecia, helping you to avoid this complication and increase your knowledge of safe aesthetic practices.

Certain areas of the face hold more risk than others of causing a complication like vascular occlusion or blindness; Dr Tim has highlighted these on an illustrative skull to include the six deep danger points and six arteries that run in parallel to your needle so that you can take extra caution when treating your patients in these areas. Download their facial vessel map to the 13 extra risky injection areas.

What is the temple or temporal lifting technique?

Dr Tim is keen to highlight a somewhat new complication, and how it shines a light on many of the issues that affect the aesthetic sector when new procedures or techniques are heralded with limited efficacy and safety data. In this case, we are discussing the temple or temporal lifting technique.

Dr Tim notes that the technique is a very clever idea that suggests if you add dermal filler into the temple, you may have a positive effect on the lower face. Although described in a 2020-published clinical paper – Clinical validation of the temporal lifting technique using soft tissue fillers – he admits reticence in relation to the entry points for the technique, as explained in his previous blog – Understanding complications: Scalp necrosis and temporal lifting. This is because the entry point and the technique are known to have caused several very severe vascular occlusions by occluding the vessel that runs anterior to the ear and supplies blood to the scalp, the superficial temporal artery. Occlusion of this vessel can cause a devastating complication with a large necrotic injury leading to scarring of the scalp and permanent hair loss which cannot be repaired with hair transplantation due to the scarring.

However, this is not the same complication reported by Dr Marina Landau et al who present a case series of patients who developed non-scarring alopecia after dermal filler injection using the posterior temple technique.

Non-scarring alopecia after temporal lifting technique

In the published paper, Non-scarring alopecia after temporal lifting technique with dermal fillers, Dr Landau et al report on six patients with a side effect of alopecia without necrotic injury following the temporal lifting technique with dermal filler.

The hypothesis is that the pressure of the injections in the scalp is causing hair follicles to die, even if the scalp itself does not necrose. Delving deeper into this theory, Dr Tim explains that pressure itself is enough to disrupt blood flow, and the medical fraternity already knows that one of the causes of male patent baldness is a decrease in blood flow to the hair follicles. Similarly, pressure and a tightening of the scalp have been postulated as a potential theory for hair loss. Therefore, it is perhaps not a surprise to consider that increasing pressure underneath the dermis, under the scalp, with dermal fillers could also cause hair loss.

Diagram of the blood vessels under the faceSadly, when new techniques are developed, the potential complications are not often a significant factor in the initial flurry of excitement and activity that goes alongside innovation. Dr Tim tends to favour an approach of waiting to see if techniques have merit and work safely rather than being one of the first to dive straight in when something new is suddenly all the rage.

When Dr Tim first openly discussed complications from the temporal lifting technique, several clinicians from around the world got in touch to report similar findings and drew his attention to at least three cases describing often devastating injuries. Sadly, they were all reticent to go on the record to discuss their observations, even via official routes, for fear of negative repercussions from reporting on other colleagues in the field. This is of course a disappointing outcome because medical complications and side effects must be reported to enable future learning – this is how medicine progresses and evolves.

Thanks to the work of Dr Landau et al, this paper gathers and describes several case reports of patients who detected discomfort and pain after dermal filler treatment to the temple, with clinicians who responded appropriately by reversing the procedure to restore blood flow, yet the patients’ hair began falling out during subsequent days. Thankfully, in almost all cases, over several months, with the prevention of necrosis (and scarring), the hair growth eventually restarted. Yet, it is important not to underplay the potential for a devastating side effect from the temporal lifting technique where a patient may suffer a permanent patch of hair loss that will never recover.

Why is the temporal lifting technique inherently risky?

Dr Tim believes that the temporal lifting technique is inherently risky because the entry point (for the cannula) is described as 1cm preauricular, precisely where the superficial temporal artery traverses the face; you can feel it pulsating if you palpate the area designated for entry.

Why this injection or entry point was chosen is somewhat unknown, and you could make the argument that placement ought to be at the right depth which would ensure safety, presumably relatively deep. However, the problem with this argument is that as you slide a large cannula up, it naturally wants to be more superficial (than a sharp needle) so getting deep is difficult.

When reflecting on such procedures, being done thousands and thousands of times, Dr Tim thinks about the likely accidents. It is therefore quite clear to him that a cannula that wants to be more superficial, when you are trying to be deep, combined with an area of skin that is covered with hair so you cannot see the depth of the cannula very well, and where you also cannot see if any skin discolouration, vascular occlusion, or decrease in blood flow occurs, combined with the requirement for a very large volume of dermal filler (approximately 1ml) placed in a single bolus in many cases, is a recipe for risk.

Get your hands on Dr Tim’s limited edition facial anatomy posters which are available to buy for your aesthetic business as a helpful tool for understanding the paths of the facial vasculature.

Should we stop carrying out the temporal lifting technique?

As with all things, the answer is a balance of risks, concludes Dr Tim. It is for you as an aesthetic clinician to decide whether you think the results that you can achieve with the temporal lifting technique justify the risks.

He would not like to do this procedure because he knows, and is satisfied, that he can get great results for his patients by not doing it, believing that he can achieve comparable results by injecting a similar quantity of dermal filler into the cheeks, temples, and the pre-auricular area using other non-surgical techniques, without the inherent uncertainty and risk of the temporal lifting technique. Therefore, he will not be learning how to perform the technique himself but refrains from judging those who achieve wonderful results, ensure safety, and believe it is worth the inherent risks.

It is a good mental exercise to think through the risks and how you could adjust your practice to decrease them when considering if you want to undertake new procedures; unexpected side effects often emerge years after practitioners first embark on new techniques so reflect and understand the risks first.

In the case of evaluating the temporal lifting technique, Dr Tim would aim to decrease the risk by not entering at the described point. He does not like being parallel with arteries using a large cannula, hence he would move the entry point more anteriorly and cross the artery. For added safety, he would use an ultrasound to attempt to find the artery before embarking on injecting. Check out, Should I buy an ultrasound scanner for my aesthetic clinic?

In terms of the dermal filler product, Dr Tim would likely use a lower viscosity product to avoid creating a bump or bulge on the head from a large bolus of filler, instead favouring evenly spreading the desired tension and product across the scalp. Educating and consenting the patient is also a crucial part of undertaking such a novel procedure to guarantee that they will get in touch if they experience any pain, allowing you to reverse the procedure quickly, if required, particularly due to the lack of visibility.

You can follow Dr Marina Landau on Instagram. Dr Tim is always keen to hear about the experiences of his followers, so, if you have any comments on the temporal lifting technique or questions for him, you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

Dermal Filler Induced Hair Loss

Dr Tim introduces the episode saying:

“There’s been a few interesting cases of alopecia as a result of temple lifting technique with dermal filler. I first came across this complication when I read a paper by Dr Marina Landau. Her paper documents a case of alopecia after temple filler and necrosis in otherwise healthy patients. In this episode I’m going to dive into this topic in more detail and discuss the factors that led to alopecia so that you can spot the signs in your own patients and increase your safety knowledge. “

Watch the full Aesthetics Mastery Show here.

You can raise questions for discussion on YouTube:

@kikistone7348 asked:

“What if it’s sculpta to fill the temples, not to lift the face? Same risk?”

Dr Tim replied:

“The additional danger comes from going under the hairline and parallel with the big temple artery.”

Read comments and join in the debate on our YouTube channel.

Subscribe to our YouTube channel for really useful regular tips and advice.  YouTube

Dermal Filler eLearning Courses

If you want to increase your knowledge about safe and effective dermal filler injectable treatments, Dr Tim Pearce offers a series of fabulous courses. The foundation level is a popular starting point, with many delegates continuing to complications courses focused around safety, including how to minimise the risk and how to handle things if the worst occurs:

Both give CPD and certificates on completion and are highly rated by our delegates.

In addition, browse our FREE downloadable resources.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.

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