Mapping the body: the temple

Sometimes, the significance a body part holds in one's clinical life changes over time. The first time I thought about the temple was during a head-and-neck tutorial, well over a decade ago. One of a small group of medical students, each clasping a human skull in our hands, I turned my own this way and that, trying intently to arrive at the correct answer to the question our anatomy demonstrator had just put to us – which part of the bony skull is the thinnest?

The word he was looking for was the pterion. Roughly corresponding to what we all know as the temple, this place – which takes its name from the Greek pteron, meaning wing (think of Hermes with wings attached to this part of his head) – is the junction of four separate skull bones, the frontal, parietal, temporal and sphenoid. Sometimes referred to in neurosurgical circles as "God's little joke", the bony pterion is not just a hazard zone because it is so thin, but also on account of a big artery, the middle meningeal, which runs immediately beneath it.

A direct blow to the pterion, or even an indirect blow to another part of the skull, may cause a fracture to this weak area, with an associated rupture of the underlying vessel. This can lead to something called an epidural haematoma, where blood builds up between the outer covering of the brain and the skull, with consequent pressure on the brain itself. Such an injury requires emergency surgery known as a craniotomy – where a hole is put in the skull, to let the blood out and so release cerebral pressure.

But this dramatic lesson is a far cry from my current temple-associated practice. Skin cancers often arise in this area, because of a person's lifetime exposure to the sun, and it is often not possible simply to sew up the hole in the skin after cutting a cancer out, since doing so can easily distort the contour of the eye. At such times, I opt for a Wolfe graft. After excising the cancer, I measure out a circle of equal size in the skin above the collar-bone (where the skin is similar) and remove it. I attach the graft to the patient's temple with tiny silk sutures. A nice pink Wolfe graft brings joy to the heart and heals with excellent cosmetic effect in just a few weeks.

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