Introduction
Temporal hollowing is a frequently underappreciated aesthetic deficit, yet its correction plays a pivotal role in full-face rejuvenation. Age-related volume loss in the temporal region not only alters lateral facial contours but also contributes to an overall skeletalised appearance. While dermal filler augmentation has emerged as the mainstay treatment for temporal atrophy, it remains a procedure that demands anatomical precision, strategic vector planning, and thoughtful product selection.
Crucially, pre-injection visual mapping—particularly with high-fidelity, sterile markers such as SKRYBE—elevates temporal augmentation from an empirical technique to a structured, anatomically guided intervention. This article explores the anatomy of the temporal fossa, the strategic relevance of visual marking, and the technical considerations for safe and reproducible outcomes in filler-based correction of temporal hollowing.
Anatomy of the Temporal Region
The anatomy of the temporal region may be considered in different ways for different types of practitioners. The same anatomic landmarks have several names associated with them, and this is a source of confusion among those initially studying the anatomy of the temporal region.
Injection anatomy would dictate the temporal region has overlying skin, an underlying fat pad, a deeper muscle and bone at its base. Reconstructive and dermatological anatomy is more complex. The skin is divided into the epidermis, the dermis and the subcutaneous fat. Deep to the subcutaneous fat, there is a fat pad. The fat pad is known by several names, such as the superficial temporal fascia, also known as the temporoparietal fascia and the temporalis fascia. This fat pad contains an artery, the superficial temporal artery, which has two branches, a superficial branch and deep branch, and so the superficial temporal fascia is therefore divided into a superficial layer and a deep layer, relevant for vascularised bi-leafed flap reconstruction purposes. Deep to this, there is an avascular layer that sits on the temporalis muscle, and is known as the temporalis fascia, and also known as the fascia of (or overlying) the temporalis muscle. The muscle is attached to the deeper structure - the bone. However, the bone has a layer of periosteum and it has, additionally, three layers within the bone - the outer cortex, the medullary cavity and the inner cortex. The temporal region has either 11 layers or 4 layers, depending on the context.
For the purposes of injection anatomy, the layers are the skin, the fat, the muscle and the bone. Within the fat, the vasculature and fat pad arrangement is important. The veins within this fascia drain the forehead and the scalp. A filler placed in this fat pad, if too cohesive, will create a dam-like effect on the draining veins and will lead to prominent veins in the forehead, which will age the patient. The large plexus of vessels within the temporalis muscle have a predictable but variable pattern, as is the case with most head and neck vascular anatomy. Accordingly, blind injection into the temporalis muscle carries with it the risk of unintended intravascular injection.
The temporal fossa is bordered by the temporal line (also known as the temporal crest) superiorly, the lateral orbital rim anteriorly, and the zygomatic arch inferiorly. Within this space, the superficial temporal fat pad—along with contributions from the deep temporal fat pad—provides the primary volume reservoir. Overlying this fat is the superficial temporal fascia, also known as the temporoparietal fascia, beneath which lies the deep temporal fascia and then the temporalis muscle.
Critically, the region is traversed by the superficial temporal artery (STA) and its frontal branch, which ascends anterior to the tragus and then crosses the zygomatic arch toward the lateral brow. The temporal branch of the facial nerve also courses within the superficial temporal fascia, particularly vulnerable in the anterior half of the temporal fossa【1】.
With aging, both fat compartments and underlying muscle volume diminish, while bone resorption along the lateral orbit contributes further to the concavity. The goal of treatment is to restore soft contour without disrupting neurovascular structures or introducing complications such as visible filler, contour irregularity, or vascular compromise.
- FB-STA = Frontal Branch of the Superficial Temporal Artery
- DTA = Deep Temporal Arteries
- MTV = Middle Temporal Vein
The Importance of Visual Marking
Anatomical complexity, variation in vascular course, and the need for vector-driven augmentation make visual pre-procedural marking an essential component of safe temporal hollowing correction. Marking enables the injector to:
- Identify safe entry points outside danger zones
- Trace arterial pathways to avoid intravascular injection
- Delineate injection planes, such as subdermal vs supraperiosteal
- Plan vector alignment for even volume restoration
When performed after antiseptic cleansing using a sterile white marker such as SKRYBE, markings remain visible throughout the injection and are skin-type inclusive. This is particularly critical in patients with darker Fitzpatrick phototypes, where contrast can otherwise be insufficient for reliable guidance. Unlike traditional pencil markings, SKRYBE’s formulation resists erasure during procedural wiping and does not compromise asepsis.
- H = Hairline,
- TC = Temporal Crest
- SOR = Superior Orbital Rim
- ZA = Zygomatic Arch
- TZ = Temple Fill Zone
Mapping Technique
1. Safe Entry Point Identification
The ideal entry point for cannula-based filler delivery lies approximately 1–1.5 cm posterior and superior to the lateral orbital rim, at the hairline level or just behind the temporal fusion line. This avoids the course of the STA and the frontal branch of the facial nerve【2】.
2. Danger Zone Demarcation
Using anatomical knowledge and palpation, the injector should mark:
- The course of the STA, often visualised or palpated anterior to the tragus, anterior to the root of the helix or anterior to the temporal hairline.
- The frontal branch path, which typically travels from 0.5 cm below the tragus to 1.5 cm above the lateral brow, along Pitanguy’s line【3】
3. Volume Distribution Zones
Visual mapping can delineate:
- Anterior temporal zone (lateral to orbital rim): to be filled conservatively
- Posterior temporal zone (more recessed, overlying temporalis): main augmentation site
- Superior temporal line: avoid crossing this boundary to prevent forehead distortion
These markings, when captured in procedural photographs, also enhance documentation and medico-legal defensibility.
Injection Technique
Injection approach is determined by anatomical depth and product selection.
Cannula Technique (Preferred for Safety)
- Cannula: 22–25G, 38–50 mm
- Plane: Deep subcutaneous or supraperiosteal
- Entry: Through pre-marked point posterior to orbital rim
- Motion: Fanning or linear threading from posterior to anterior
- Volume: 0.5–1.2 mL per side, titrated to severity of hollowing
Needle Technique (For Supraperiosteal Bolus)
- Entry: At superior zygomatic arch
- Plane: Supraperiosteal
- Volume: Small boluses (0.1–0.2 mL)
- Reserved for advanced practitioners with excellent anatomical familiarity
In all approaches, aspiration and slow injection are imperative. Avoiding boluses in mobile fat compartments is critical to minimise nodularity or vascular compromise.
Product Considerations
Product selection must align with the depth of placement, desired duration, and tissue quality.
- Hyaluronic Acid (HA) Fillers: Products with high G’ and cohesivity are suited for deep placement (e.g. Restylane Volyme, Teosyal RHA 4).
- Calcium Hydroxylapatite (CaHA): Used with caution; ideal in deeper compartments with careful dilution.
- Polynucleotides or Bioremodellers: May improve skin elasticity and support tissue tone, often used adjunctively【4】.
Risks of Poor Planning
Failure to visually map and appreciate depth leads to avoidable complications:
- Intravascular injection: STA injury can result in embolic phenomena, including blindness【5】
- Contour irregularities: Especially when product is misplaced in the superficial plane
- Mass effect on nerve branches: Can result in temporary facial asymmetry
Pre-injection mapping addresses these by preserving anatomical awareness under procedural stress.
When to Mark
- During consultation: Enables collaborative planning with patient input
- Immediately post-cleansing: To retain sterility and marking clarity
- Before documentation: Clinical photography with SKRYBE markings enhances transparency and teaching utility
Marking should never occur prior to disinfection, as this leads to duplication, smudging, and increased contamination risk. Single-step, sterile post-cleansing marking with SKRYBE FMD aligns with both practical and infection control guidelines.
Clinical Integration
In high-volume practices or teaching centres, mapping also standardises technique across teams. It improves reproducibility, enables audit, and facilitates clearer complication reporting.
In a 2023 survey of aesthetic injectors across five international training centres, 89% reported improved confidence and reduced complication rates when visual marking was incorporated into pre-injection workflow【6】.
Conclusion
Temporal hollowing is a deceptively nuanced region with profound aesthetic influence. Its treatment requires more than aesthetic instinct—it requires structured anatomical reasoning, meticulous planning, and visual clarity.
Pre-injection marking, particularly with sterile, high-contrast tools like SKRYBE, transforms a traditionally empirical procedure into one guided by topographical precision. It allows the practitioner to preserve form, avoid critical structures, and deliver symmetry that is repeatable and teachable.
In modern aesthetic medicine, the aesthetic begins at the anatomical—one line at a time.
References
- Mendelson, B. C., & Wong, C. H. (2013). Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plastic Surgery, 37(5), 1007–1015.
- Lambros, V. S. (2012). Volumetric facial aging and the role of minimally invasive volumetric techniques. Clinics in Plastic Surgery, 39(4), 519–529.
- Pitanguy, I. (1966). Surgical importance of the temporal branch of the facial nerve. Plastic and Reconstructive Surgery, 38(4), 349–352.
- Sundaram, H., & Carruthers, J. (2015). Evaluation of the safety of calcium hydroxylapatite for soft-tissue augmentation. Plastic and Reconstructive Surgery, 136(5 Suppl), 81S–90S.
- Beleznay, K., Carruthers, J. D., Humphrey, S., & Jones, D. (2014). Avoiding and treating blindness from fillers: a review of the world literature. Dermatologic Surgery, 40(7), 805–817.
- Saldanha, A., et al. (2023). Visual planning and complication reduction in aesthetic filler procedures: a multicenter observational study. Journal of Clinical Aesthetics, 15(9), 34–42.
