Journal of Plastic, Reconstructive & Aesthetic Surgery 77 (2023) 271–273
Correspondence and Communications
Comparative study of the
penetration force between the
superficial and deep temporal
fascia for easier temple
augmentation technique using
hyaluronic acid filler
Dear Sir,
Introduction
Filler injection is a commonly performed cosmetic proce-
dure, and temple augmentation is one of the most fre-
quently performed filler procedures. Gradual volume reduc-
tion of the soft tissues in the temple area results in tem-
ple depression. The temple region shrinks in the absence of
congenital fat or due to weight loss that may occur because
of aging and makes an individual appear older.1 Hyaluronic
acid (HA) filler, the most common soft tissue filler, can aug-
ment temple hollowness and create a smooth shape. How-
ever, there are multiple layers in the temple area, and sev-
eral techniques to augment the temple area using HA fillers
have been recommended.
Some studies have suggested that the filler should be in-
jected deep into the periosteal layer between the tempo-
ral fossa and temporalis in the depressed area.2 However,
this procedure requires a relatively large amount of filler,
and it is also challenging to accommodate the entire ex-
tinguished part in cases of a wide region. The possibility
of vascular complications is another limitation of the pro-
cedure.3 Thus, injections between the superficial tempo-
ral fascia (STF) and the deep temporal fascia (DTF) are a
commonly performed and effective technique.4 If the lay-
ered structure of the temple area is clearly understood and
each structure is distinguished while performing the pro-
cedure, can be performed in a safer and more effective
manner.
The presence of quantitative data increases the efficacy
of the procedure. Therefore, we aimed to investigate the
forces required to penetrate the STF and DTF and evalu-
ated the difference between the forces and propose an easy
technique for temple augmentation.
Materials and methods
Twelve hemifaces were used to compare the penetration
forces (PF) required during temple area augmentation. The
temporal fascia was exposed by removing the skin and the
subcutaneous tissues around the temple area and each layer
of the temporal fascia were retracted. The PF required for
the retracted STF and DTF were measured (Figure 1). The
upper point was set at 2 cm lateral to the lateral eyebrow,
and the lower point at 2 cm above the zygomatic arch in a
line perpendicular to the upper point.
The PF was measured using an injection model equipped
with a 21G cannula on a multiTest 2.5-d device (Mecmesin
Limited). To prevent other confounding factors, the fascia
was firmly fixed throughout the process; the average value
was derived by measuring the left and right sides thrice.
Results
On ultrasonography, the STF and DTF appeared bright and
hyperechoic compared to the surrounding tissue. The sub
superficial musculoaponeurotic system (subSMAS) fat, lo-
cated between the two fascial layers, appeared relatively
dark and hypoechoic owing to the weak reflection of the
signal compared to that from the surrounding tissue. The
DTF is presented as a single layer in the upper portion of
the temple area and subsequently divided into the superfi-
cial and deep layers 2–3 cm above the zygomatic arch.
At the upper point, the mean PF required for the STF
and DTF was 7.5 ± 2.9 N and 13.2 ± 3.2 N, respectively. The
mean PF required for the superficial layer of the DTF at the
lower point was 11.5 ± 3.3 N.
Discussion
Generally, various sites of filler injections in the temple area
have been recommended. The first is the pre-periosteal
layer beneath the temporalis. However, a large amount of
filler is required when injected into a layer deeper than the
muscle. The second recommendation is between the STF
and DTF. Our study indicates that relatively challenging to
penetrate the DTF.
Results of the study indicate that PF with a cannula dif-
fers between the STF and DTF, and this can be used as a
guideline for clinicians to differentiate each structure dur-
ing the procedure. Therefore, placing the cannula tip be-
 K.-L. Lee, G.-W. Hong, W. Lee et al.

Figure 1 Procedure for measuring penetration force of the dissected temporal fascia using by multiTest 2.5-d device.

Figure 2 Ultrasonographic image of hyaluronic acid filler (HA filler) injected between the superficial temporal fascia (STF) and
deep temporal fascia (DTF).

tween the STF and DTF is a relatively safe technique. As
is known, the middle temporal vein is located deep in the
superficial layer of the DTF, resulting in a risk of vascular
damage during deep injections. Vessels in the temple area
can be detected using Doppler ultrasonography, and filler
injection in the space between the STF and DTF is one of
the most straightforward techniques (Figure 2). A small-
diameter cannula can perform more specific filler injection,
it is safer to use a larger-diameter cannula. When a 21G
cannula is used, the patient is likely to perceive the can-
nula perforating the STF easily and injecting the HA filler
between the STF and DTF.5
In this study, based on the measured value of the struc-
tural tension that applies pressure to the surface, we in-
tended to establish a new clinical approach by examining
the relationship between the tension and changes in the

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 77 (2023) 271–273
physical properties of the filler. Based on these, we pro-
pose that injecting fillers into the space between the STF
and DTF is a comparatively easier and safer technique.
Statement of contribution
1. Kyu-Lim Lee, PhD: overall planning the research, data
acquisition, analysis and interpretation, and major draft-
ing and revision of manuscript submission.
2. Gi-Woong Hong, MD, PhD: data acquisition, analysis
and interpretation, and major drafting and revision of
manuscript submission.
3. Won Lee, MD, PhD: overall planning of the research, data
acquisition, and analysis, interpretation, drafting and re-
vision of the manuscript.
4. Hee-Jin Kim, DDS, PhD [Corresponding author]: providing
the anatomical and clinical opinion for conception, over-
all organization, and direct supervision of the research.
Ethical approval
Not required.
Funding
This study was supported by N-Finders co., Ltd (2019-31-
1011).
Declaration of Competing Interest
The authors declare that there is no conflict of interest re-
garding the publication of this article.
Acknowledgments
The authors sincerely thank those who donated their bodies
to science for anatomical research. The results of such re-
search may increase humanity’s overall knowledge, which
can improve patient care. Therefore, these donors and
their families deserve the highest gratitude. The authors
thank Shihyun Kim from Boston University and Soowan Kim
from Johns Hopkins University for assisting in revising the
manuscript.
References
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Volumization of the young and the old temple using a highly
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doi:10.1111/jocd.14109.
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2. Sykes JM, Cotofana S, Trevidic P, et al. Upper face: clini-
cal anatomy and regional approaches with injectable fillers.
Plast Reconstr Surg 2015;136:204S–218S. doi:10.1097/PRS.
0000000000001830.
3. Yang Q, Qiu L, Yi C, et al. Reversible alopecia with local-
ized scalp necrosis after accidental embolization of the parietal
artery with hyaluronic acid. Aesthetic Plast Surg 2017;41:695–9.
doi:10.1007/s00266- 017- 0841- z.
4. Huang RL, Xie Y, Wang W, et al. Anatomical study of temporal fat
compartments and its clinical application for temporal fat graft-
ing. Aesthet Surg J 2017;37:855–62. doi:10.1093/asj/sjw257.
5. Lee W, Park JW, Yang EJ. Temple augmentation by injecting a
hyaluronic acid filler between the superficial and deep temporal
fasciae. J Cosmet Dermatol 2022 online ahead of print. doi:10.
1111/jocd.15004.
Kyu-Lim Lee
Division in Anatomy and Developmental Biology,
Department of Oral Biology, Human Identification
Research Institute, BK21 FOUR Project, Yonsei University
College of Dentistry, Seoul, South Korea
E-mail address: kyulimlee@yuhs.ac
Gi-Woong Hong
Samskin Plastic Surgery Clinic, Seoul, South Korea
E-mail address: cosmetic21@hanmail.net
Won Lee
Yonsei E1 Plastic Surgery Clinic, Anyang, South Korea
E-mail address: e1clinic@daum.net
Hee-Jin Kim∗
Division in Anatomy and Developmental Biology,
Department of Oral Biology, Human Identification
Research Institute, BK21 FOUR Project, Yonsei University
College of Dentistry, Seoul, South Korea
Department of Materials Science & Engineering, College
of Engineering, Yonsei University, Seoul 03722, South
Korea
E-mail address: hjk776@yuhs.ac
∗
Room 601, Department of Oral Biology, Yonsei
University College of Dentistry, 50-1 Yonsei-ro,
Seodaemun-gu, Seoul, 03722, South Korea
© 2022 Published by Elsevier Ltd on behalf of British Association of
Plastic, Reconstructive and Aesthetic Surgeons.
https://doi.org/10.1016/j.bjps.2022.12.005