Postoperative temporal hollowing: Is there a surgical approach that prevents this complication? A systematic review and anatomic illustration

Background Temporal hollowing is a common complication following surgical dissection in the temporal region. Our objectives were to: (1) review and clarify the temporal soft tissue relationships – supplemented by cadaveric dissection – to better understand surgical approach variations and elucidate potential etiologies of postoperative hollowing; (2) identify if there is any evidence to support a surgical approach that prevents hollowing through a systematic review. Methods Cadaveric dissection was performed on six hemi-heads. A systematic review of the literature was undertaken to identify surgical approaches with a decreased risk of postoperative hollowing. Results A total of 1212 articles were reviewed; 19 of these met final inclusion criteria. Level I and II evidence supports against the use of a dissection plane beneath the superficial layer of the deep temporal fascia or through the intermediate temporal fat pad. Level II evidence supports preservation of the temporalis muscle origin – no evidence is available to support other temporalis resuspension techniques. For intracranial exposure, refraining from temporal fat pad dissection (Level I Evidence) and use of decreased access approaches such as the minipterional craniotomy (Level I Evidence) appear to minimize temporal soft tissue atrophy. Conclusions This study highlights the significance of preservation of the temporal soft tissue components to prevent hollowing. Preserving the temporalis origin and avoiding dissection between the leaflets of the deep temporal fascia or through the intermediate temporal fat pad appear to minimize this complication.