Utilization of Intraparotid Segments of Superficial Temporal Vessels for Head and Scalp Free Flap Microanastomosis: A Clinical, Histological, and Cadaveric Study

Abstract

Background The superficial temporal vessels (STV) are an underutilized target for head and neck microvascular reconstruction. Most surgeons regard the dissection as difficult, unreliable, and the anastomosis prone to vasospasm. The intraparotid course of the STV may provide more reliable flow without accompanying morbidity.

Methods A retrospective review of patients who underwent head and scalp free flap reconstruction utilizing STV intraparotid segment was performed. Demographic factors such as intraoperative and postoperative complications are reported. Five bilateral cadaver heads were dissected to describe the relationship to the facial nerve. STV histology was performed on four of the cadavers, noting intraluminal diameter and vessel wall thickness.

Results Thirty-nine patients underwent free flap reconstruction with anastomosis to intraparotid STVs. Defect etiology included tumor resection (71.8%), traumatic brain injury (10.3%), intracranial bleed (12.8%), and acute trauma (5.1%). Flaps transferred included anterolateral thigh (51.3%), latissimus (33.3%), thoracodorsal artery perforator (7.7%), radial forearm (2.8%), and vastus lateralis (5.1%). Two flaps (5.1%) required takeback for arterial thrombosis, with one incidence of total flap loss (2.8%). There were no instances of transient or permanent facial nerve damage nor sialocele. On cadaver dissection, three distinct vessel segments were identified. Segments 1 and 2 represented the STVs superior to the upper tragal border. Segment 3 (intraparotid segment) began at the upper tragal border and STVs enlarged with a targeted anastomosis point at an average of 16.3 mm medial and 4.5 mm inferior to the upper border of the tragus. The frontal branch coursed 11.7 mm inferior and 11.5 mm anterior to this point. On histology, the intraluminal diameter of segment 3 was significantly larger than segment 2 (1.2 vs. 0.9 mm, p = 0.007).

Conclusion Head and neck free flap reconstruction with microanastomosis to the intraparotid segment of STVs can be safely and reliably performed.

Keywords

head and neck reconstruction - superficial temporal artery - superficial temporal vessels

Note

This work was presented at the American Society for Reconstructive Microsurgery Annual Meeting 2019 and the Midwestern Association of Plastic Surgeons 2019.

• References

• 1 Hallock GG. The extended temporoparietal fascia “non-free” flap. Ann Plast Surg 1989; 22 (01) 65-68
• 2 Panje WR, Morris MR. The temporoparietal fascia flap in head and neck reconstruction. Ear Nose Throat J 1991; 70 (05) 311-317
• 3 Harii K, Omori K, Omori S. Hair transplantation with free scalp flaps. Plast Reconstr Surg 1974; 53 (04) 410-413
• 4 Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps. Plast Reconstr Surg 1984; 74 (05) 603-610
• 5 Kim YO, Park BY. Reverse temporalis muscle flap: treatment of large anterior cranial base defect with direct intracranial-nasopharyngeal communication. Plast Reconstr Surg 1995; 96 (03) 576-584
• 6 Nakajima H, Imanishi N, Minabe T. The arterial anatomy of the temporal region and the vascular basis of various temporal flaps. Br J Plast Surg 1995; 48 (07) 439-450
• 7 Slavin ML. Brow droop after superficial temporal artery biopsy. Arch Ophthalmol 1986; 104 (08) 1127
• 8 Tomsak RL. Superficial temporal artery biopsy. A simplified technique. J Clin Neuroophthalmol 1991; 11 (03) 202-204
• 9 Hamada J, Todaka T, Yano S, Kai Y, Morioka M, Ushio Y. Vertebral artery-posterior inferior cerebellar artery bypass with a superficial temporal artery graft to treat aneurysms involving the posterior inferior cerebellar artery. J Neurosurg 2002; 96 (05) 867-871
• 10 Doscher M, Charafeddine AH, Schiff BA. , et al. Superficial temporal artery and vein as recipient vessels for scalp and facial reconstruction: radiographic support for underused vessels. J Reconstr Microsurg 2015; 31 (04) 249-253
• 11 Turin SY, Walton RL, Dumanian GA, Hijjawi JB, LoGiudice JA, Alghoul M. Current Practices in the Management of Postoperative Arterial Vasospasm in Microsurgery. J Reconstr Microsurg 2018; 34 (04) 242-249
• 12 Maricevich M, Lin LO, Liu J, Chang EI, Hanasono MM. Interposition vein grafting in head and neck free flap reconstruction. Plast Reconstr Surg 2018; 142 (04) 1025-1034
• 13 Wada K, Otani N, Toyooka T, Takeuchi S, Tomiyama A, Mori K. Superficial temporal artery to anterior cerebral artery hemi-bonnet bypass using radial artery graft for prevention of complications after surgical treatment of partially thrombosed large/giant anterior cerebral artery aneurysm. J Stroke Cerebrovasc Dis 2018; 27 (12) 3505-3510
• 14 Takeuchi S, Koike T, Tanaka R. Anastomosis of the superficial temporal artery to the middle cerebral artery with the interposed occipital artery graft in moyamoya disease: case report. Surg Neurol 1997; 48 (06) 615-619
• 15 Büyükmumcu M, Güney O, Ustün ME, Uysal II, Seker M. Proximal superficial temporal artery to proximal middle cerebral artery bypass using a radial artery graft: an anatomic approach. Neurosurg Rev 2004; 27 (03) 185-188
• 16 Chardigny C, Jebara VA, Acar C. , et al. Vasoreactivity of the radial artery. Comparison with the internal mammary and gastroepiploic arteries with implications for coronary artery surgery. Circulation 1993; 88 (5 Pt 2): II115-II127
• 17 Mu D, Luan J, Mu L, Xin M. Repetitive arterial crisis of deep inferior epigastric perforator flap after mental stress: a case report. J Reconstr Microsurg 2011; 27 (06) 337-342
• 18 Meybodi AT, Lawton MT, El-Sayed I. , et al. The infrazygomatic segment of the superficial temporal artery: anatomy and technique for harvesting a better interposition graft. Oper Neurosurg (Hagerstown) 2017; 13 (04) 517-521
• 19 Menovsky T, Sener S, Kamerling N, Plazier M, Boogaarts J, Lukes A. Preservation and microsurgical repair of the superficial temporal artery during pterional craniotomy. World Neurosurg 2016; 89: 72-77
• 20 Tayfur V, Edizer M, Magden O. Anatomic bases of superficial temporal artery and temporal branch of facial nerve. J Craniofac Surg 2010; 21 (06) 1945-1947
• 21 Pinar YA, Govsa F. Anatomy of the superficial temporal artery and its branches: its importance for surgery. Surg Radiol Anat 2006; 28 (03) 248-253
• 22 Kim BS, Jung YJ, Chang CH, Choi BY. The anatomy of the superficial temporal artery in adult koreans using 3-dimensional computed tomographic angiogram: clinical research. J Cerebrovasc Endovasc Neurosurg 2013; 15 (03) 145-151
• 23 Gray H, Carter HV. Anatomy of the human body. PA: Lea and Febiger; 1918
• 24 Tall J, Björklund TC, Skogh AC, Arnander C, Halle M. Vascular complications after radiotherapy in head and neck free flap reconstruction: clinical outcome related to vascular biology. Ann Plast Surg 2015; 75 (03) 309-315
• 25 Lahtinen S, Koivunen P, Ala-Kokko T. , et al. Complications and outcome after free flap surgery for cancer of the head and neck. Br J Oral Maxillofac Surg 2018; 56 (08) 684-691
• 26 Carniol ET, Marchiano E, Brady JS. , et al. Head and neck microvascular free flap reconstruction: An analysis of unplanned readmissions. Laryngoscope 2017; 127 (02) 325-330
• 27 Mücke T, Ritschl LM, Roth M. , et al. Predictors of free flap loss in the head and neck region: a four-year retrospective study with 451 microvascular transplants at a single centre. J Craniomaxillofac Surg 2016; 44 (09) 1292-1298
• 28 Hansen SL, Foster RD, Dosanjh AS, Mathes SJ, Hoffman WY, Leon P. Superficial temporal artery and vein as recipient vessels for facial and scalp microsurgical reconstruction. Plast Reconstr Surg 2007; 120 (07) 1879-1884
• 29 Halvorson EG, Cordeiro PG, Disa JJ, Wallin EF, Mehrara BJ. Superficial temporal recipient vessels in microvascular orbit and scalp reconstruction of oncologic defects. J Reconstr Microsurg 2009; 25 (06) 383-387
• 30 Maral T, Borman H. Reconstruction of the upper portion of the ear by using an ascending helix free flap from the opposite ear. Plast Reconstr Surg 2000; 105 (05) 1754-1757
• 31 Tsuruta T, Masuko S, Watanabe H. Immunohistochemical study of the sympathetic and sensory innervation to the blood vessels of the dog forepaw. Tohoku J Exp Med 1992; 168 (04) 549-560
• 32 Janis JE, Hatef DA, Ducic I. , et al. Anatomy of the auriculotemporal nerve: variations in its relationship to the superficial temporal artery and implications for the treatment of migraine headaches. Plast Reconstr Surg 2010; 125 (05) 1422-1428
• 33 Lei T, Xu DC, Gao JH. , et al. Using the frontal branch of the superficial temporal artery as a landmark for locating the course of the temporal branch of the facial nerve during rhytidectomy: an anatomical study. Plast Reconstr Surg 2005; 116 (02) 623-629 , discussion 630
• 34 Shin KJ, Shin HJ, Lee SH, Koh KS, Song WC. Surgical anatomy of the superficial temporal artery to prevent facial nerve injury during arterial biopsy. Clin Anat 2018; 31 (04) 608-613