Chapter 9: Temple

INTRODUCTION

The temple is a common area for skin cancer. As discussed in the introduction to this section, the temple includes a danger zone containing the temporal branch of the facial nerve and the superficial temporal artery. The temporal branch of the facial nerve innervates the frontalis muscle giving rise to the movements of facial expression for the eyebrows and forehead.

The area is composed of skin, subcutaneous fat, superficial and deep temporal fascia, and temporalis muscle. The nerve lies immediately beneath the superficial fascia. The course of the nerve places it at risk of injury during surgery over the zygomatic arch and on the temple and lateral forehead. Its usual course is from a point 5 mm below the tragus to a point 15 mm above the lateral termination of the eyebrow. Over the zygomatic arch, it is found about 2.5 cm lateral to the lateral canthus, placing it about halfway between the lateral canthus and the superior helix (see Branches of the Facial Nerve for a diagram of the facial nerve).

There are several considerations when choosing a closure for a temple defect.^1,2 Any closure in this area can put tension on the lateral canthus or the eyebrow. A small amount of distortion is acceptable as it will settle after a few weeks. Additional tension may leave the patient with a permanently raised eyebrow or distortion of the lateral canthus and eyelids.

Side-to-side closure is often possible due to the laxity in the preauricular region beneath the temple. Redundant skin from this area can also be advanced, transposed or rotated superiorly. If none of these is an option, skin grafts may be used. If the defect is located in the concave area of the temple, second intention healing is also an option.

SIDE-TO-SIDE CLOSURE

Advantages

• The closure stays within the surgical area

• Scars can sit within, run parallel to or are extensions of, the radial rhytides emanating from the lateral canthus (crow’s feet)

• Suitable for closure of quite large defects

Disadvantage

• A long, straight line results from closure of larger defects

Technique

1. Using skin hooks, test for the best direction of closure. Ellipses are often best oriented in a radial fashion as an extension of the creases radiating out from the lateral canthus in horizontal and oblique directions. On occasion for small defects oriented vertically, or defects closer to the hairline, a vertical ellipse can be performed (see Fig. 9.1).³ Place the skin hooks ...