Concept: Superficial temporal artery
Limited information is available about the anatomical feasibility and clinical applications of flaps based on distal divisions of the superficial temporal artery (STA). The aim of this study was to investigate the anatomy of the STA, focusing on the number and reliability of distal branches and to show representative cases for the use of such flaps for zygomatic, parieto-frontal and occipital reconstructions.
In this 3-dimensional video, we perform a side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery (STA) to provide flow augmentation in a symptomatic 59-yr-old male with bilateral internal carotid artery occlusion at the origin, and left M1 segment occlusion. The patient suffered multiple left hemispheric strokes despite maximal medical therapy and was found to have poor hemodynamic reserve in the left hemisphere during evaluation with regional and global blood oxygenation level-dependent functional magnetic resonance imaging with CO2-challenge as well as quantitative magnetic resonance angiography and noninvasive optimal vessel analysis pre- and post-acetazolamide challenge. Postoperatively, the patient did very well and his hemodynamic studies improved significantly. The importance of this technique relies on the fact that we are using a single donor vessel to perform 2 anastomoses, and carries the following advantages: (1) the frontal STA branch remains intact and therefore can still be used at a later time if further revascularization is needed; (2) wound complications related to devascularizing the scalp from harvesting both STA branches are reduced; (3) 2 vascular territories are augmented (frontal and temporal) while using a single donor; (4) we are maximizing donor potential and optimizing cut flow index (CFI; total bypass flow postanastomosis divided by bypass cut flow) by flow augmenting 2 separate vascular beds therefore increasing demand. To explain that fourth point further: if the STA donor is able to carry a maximum 100 mL/min when cut, and after performing the first anastomosis bypass flow is only 37 mL/min, CFI will be 37/100 = 0.37, reflecting low demand, a poor indicator of graft patency, as previously published.1,2 By adding a second anastomosis which demands an additional 60 mL/min from the same STA donor, CFI (60 + 37)/100 improves to 1. Institutional Review Board approval was obtained for the review of patient chart and video files. Informed consent was obtained directly from the patient via telephone regarding use of media for educational and publication purposes.
Successful total scalp replantation was performed in our case. Based on the angiosome concept and anatomical study, the avulsed scalp survived with unilateral anastomosis of the superficial temporal artery and superficial temporal vein, largely due to the presence of rich arterial and venous arcades in the scalp. The patient currently has no problems with activities of daily living, although total hypoaesthesia and dysfunction of the left frontal muscle of the forehead are present. In addition, the combined findings of hair growth pattern indicated the vascular territories of the scalp skin.
With the current tendency of increasing minimally invasive cosmetic surgeries, some rare but disastrous complications of facial filler injections come into sight, such as visual loss. The study aims to investigate the possible route that the injected droplet accesses the ophthalmic artery to explain and prevent such devastating complications. We searched the National Library of Medicine’s PubMed database for cases of visual loss secondary to cosmetic facial filler injection, and reviewed relevant case reports/surveys, as well as accompanying references. Data obtained were analyzed, with special interest in injected sites and filler material, and clinical features of visual loss. Based on the anatomy of facial vessels, we inferred the possible route of injected droplet migrating from injection sites to ophthalmic artery. Most physicians propose a retrograde embolic mechanism, but the culprit artery when injecting different sites is not determined. We consider accidentally breaking into supraorbital artery or supratrochlear artery may cause occlusion of ophthalmic artery when injecting into glabella or forehead region. Speaking of the nasolabial fold and nasal dorsum region, any injections in the anastomosis of the dorsal nasal artery, angular artery, and lateral nasal artery can lead to retrograde embolism. Similarly, in the temporal region, we believe there is abnormal anastomosis between frontal branch of superficial temporal artery from external carotid artery and supraorbital artery from ophthalmic artery. In our hypothesis, we can explain the accompanying brain infarction after iatrogenic visual loss. If the injecting pressure is forceful enough, it may push the embolic materials into middle cerebral artery. Although iatrogenic ophthalmic artery occlusion is a rare complication after the facial filler injection surgery, it is usually devastating. Both the patient and the surgeon should be aware of the risk of irreversible blindness. Ideally, the injection sites should avoid the small vessels nearby, the injecting force and velocity should be as gentle and slow as possible.
The face is unique because functional and aesthetic considerations are equally important. Extensive deep chemical burns of the face are usually reconstructed with flaps. In males, the use of the hair - bearing superficial temporal artery flap has the advantage of achieving a satisfactory outcome with regards to both function and aesthetics.
Superficial temporal artery (STA) -to- superior cerebellar artery (SCA) bypass is associated with a relatively high risk of surgical complications, such as hematoma and/or edema caused by temporal lobe retraction. Therefore, the right side is typically used to avoid retraction of the left temporal lobe. In this report, we present a case of left STA-SCA bypass with anterior petrosectomy to avoid retraction of dominant side temporal lobe and describe the surgical technique in detail.
A 68-year-old man presented with rapid swelling of the right forehead 11 days after sustaining a laceration secondary to a fall. Presumed to be an abscess due to retained foreign body, needle aspiration was performed and arterial blood obtained. Doppler ultrasound revealed a 3 cm mixed echogenicity lesion with ‘see-sawing’ internal Doppler flow arising from the superficial temporal artery (STA), in keeping with a pseudoaneurysm. Treatment options including interventional radiology and open surgery were considered. Open operative intervention with direct surgical ligation provided an excellent outcome. Delayed pseudoaneurysm of the STA is a rare complication of trauma but should be considered in the differential of a traumatic lateral forehead swelling to prevent complications and inappropriate investigations and management.
A variety of island flaps can be based on the superficial temporal artery with variable tissue composition. They can be used for defect reconstruction, cavity resurfacing, facial hair restoration, or contracture release.
Variations in the relationship of the retromandibular vein to the facial nerve have been widely reported due to their relevance for surgical approaches in parotid, osteotomy and mandibular condyle surgery. In the context of the retromandibular retroparotid approach, remaining deep to the retromandibular vein is advised to decrease the likelihood of encountering the facial nerve during mandibular condyle surgery. In the present report, an unusual variant of the superficial temporal vein lying superficial to the facial nerve is described. This represents a variation of the venous branching pattern within the parotid gland, whereby the superficial temporal vein joins the maxillary vein inferior to its usual communication. These findings are discussed in the context of commonly used surgical approaches to the mandible for condylar trauma or osteotomy surgery.
Most patients with reconstruction for extensive scalp defects require the use of a free flap. The suitability of the recipient vessel has a major impact on the surgery and postoperative outcome. Flaps that can be used to reconstruct the total scalp with a single flap include the latissimus dorsi (LD) and omental flaps; the LD flap is generally preferred since the omental flap results in relatively larger donor site morbidity. The recipient vessel most commonly used for scalp defect reconstruction is the superficial temporal vessel. The authors report a patient with successful total scalp reconstruction using a free omental flap on a patient whose bilateral superficial temporal arteries could not be used and who did not have available LD on both sides due to previous LD free flap surgeries for recurrent scalp angiosarcoma. In this patient, direct anastomosis of the flap to the right facial artery was performed without pedicle lengthening, such as vein graft or arteriovenous loops, and favorable outcome was achieved in terms of facial contour after recovery. The free omental flap is useful for reconstruction of extensive scalp defects without additional complex surgical procedures when other flaps are not viable or when the recipient vessel is located at a far distance.