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CC BY-NC-ND 4.0 · Asian J Neurosurg
DOI: 10.1055/s-0045-1809943
Original Article

The Relationship between the Frontal Branch of the Superficial Temporal Artery and the Temporal Hairline in Bicoronal Incisions: Cadaveric and Clinical Study

Patawee Tangkatitham
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
,
Kitiporn Sriamornrattanakul
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
,
Nasaeng Akharathammachote
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
,
Thirawass Phumyoo 
2   Division of Anatomy, Department of Basic Medical Science, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
,
I-sorn Phoominaonin 
3   Department of Health Technology, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
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Abstract

Background

Classic bicoronal skin incisions for bifrontal craniotomy are usually performed near the course of the superficial temporal artery (STA). This frequently results in injuries to the frontal branch (fSTA) or even the STA's main trunk. We investigate the usual course of the fSTA and evaluate a previously proposed modification to bicoronal scalp incisions for its rate of STA preservation.

Materials and Methods

Sixteen sides of cadaveric heads were dissected. We investigated the location of the fSTA in relation to the temporal peak of the hairline. We also performed a retrospective study of 19 patients with cerebral aneurysms who underwent microsurgery using the modified bicoronal incision. The patients were treated at our facility between June 2017 and Jan 2022. Patients' data were retrospectively reviewed and evaluated for postoperative STA preservation.

Results

The majority of fSTAs (68.75%) passed through and just anterior to the temporal peak. The average distances between the fSTA and the temporal peak from the anterior and posterior aspects were 0.44 (0.2–0.7) cm and 0.52 (0.3–0.8) cm. The mean distance between the STA bifurcation and the zygomatic root was 3 cm. Using the modified bicoronal scalp incision, the right fSTA of 14/19 (73.7%) patients and the left fSTA of 16/19 (84.2%) patients were preserved in the scalp flap.

Conclusion

The most anterior part of the fSTA was located very close to the temporal peak of the hairline. The modified bicoronal skin incision for bifrontal craniotomy and modified transbasal craniotomy was an effective means of STA preservation.


 

Keywords

bicoronal incision - modified bicoronal incision - frontal branch of STA - hairline - superficial temporal artery - temporal peak

Introduction

The bicoronal scalp incision for a transcranial approach was first introduced in 1907.[1] Also, the bicoronal incisions are frequently used in craniofacial surgeries before 1970.[2] [3] [4] [5] [6] [7] [8] The classic bicoronal incision (also known as a Souttar incision) begins just above the zygomatic arch and curves slightly anteriorly at the midline to meet the same point above the opposite zygomatic arch ([Fig. 1]). The starting point needs to be within 1 cm of the tragus to preserve the superficial temporal artery (STA). The incision then follows a course of 3 cm posterior to the hairline.[5] [8] [9] [10]

Zoom
Fig. 1 Classic (dashed white line) and modified (dashed yellow line) bicoronal incisions. The classic incision begins just above the zygomatic arch and curves slightly anteriorly at the midline to meet the same point above the opposite zygomatic arch. The modified incision begins just posterior to the temporal peak (red arrow) on both sides and extends just posterior to the hairline (black line) toward the widow peak (blue arrow).

To date, there have been no reports of the STA preservation rate after classic bicoronal incisions. However, Suanchan et al found a mean distance from the STA to the anterior edge of the ear cartilage of 0.6 cm at the level of the superior border of the zygomatic root. They reported a mean angle between the orbitomeatal line and the axis of the parietal branch of the STA (pSTA) of 88.8 degrees (75–95 degrees).[11] These small distances suggest that the classic bicoronal incision carries a high risk of injury to the pSTA and the main trunk of the STA (mSTA).

Several studies[12] [13] [14] [15] [16] have described a basal interhemispheric approach (IHA) via a modified transbasal bifrontal craniotomy[9] for clipping aneurysms of the anterior communicating artery (AcoA)using a modified bicoronal incision. This incision begins at the temporal (temple) peak and curves superiorly just posterior to the hairline toward the widow peak, where it meets the equivalent incision coming from the opposite temporal peak. At the midline, the incision follows the widow peak ([Fig. 1]).[12] [13] [14] [15] [16] In the modified craniotomy, the skull flap incorporates the anterior wall of the frontal sinus and the superior part of the superior orbital rim. This successfully facilitated unlimited access to lesions at the anterior base of the skull.[9]

Although there have been numerous cadaveric and imaging studies of the STA,[17] [18] [19] the exact course of the fSTA has not previously been described, especially in relation to the hairline. This study aimed first to determine the course of the fSTA in relation to the hairline in cadaveric heads; and, second, to evaluate the modified bicoronal incision and its rate of fSTA preservation in clinical cases.


 

Materials and Methods

Sixteen sides of adult cadaveric heads were dissected to determine the course of the fSTA in relation to the temporal and frontal hairline. The distance between the most anterior part of the fSTA and the temporal peak of the hairline was measured. If the most anterior part of the fSTA was located anterior to the temporal peak, the distance was reported as a positive value, and vice versa. The distances from the STA bifurcation to the zygomatic arch were also measured ([Fig. 2]).

Zoom
Fig. 2 The relationship between the most anterior part of the fSTA and the temporal peak. (A) The hairline (white line), temporal peak (yellow dot), widow peak (black arrow), and sideburn (blue arrow) were identified. The red lines show the courses of the mSTA, fSTA, and pSTA. The distances between the most anterior part of the fSTA and the temporal peak (a) were measured. (B) After the skin was reflected through the subcutaneous plane, the temporal peak (yellow dot) was marked and the fSTA (dashed red line), pSTA, and mSTA were dissected. The distances between the most anterior part of the fSTA and the temporal peak (a) and between the STA bifurcation and the zygomatic arch (b) were measured. fSTA, frontal branch of the STA; mSTA, main trunk of the STA; pSTA, parietal branch of the STA; STA, superficial temporal artery.

Patients with AcoA aneurysms who underwent clipping via a modified transbasal bifrontal craniotomy[9] and IHA using the modified bicoronal skin incision ([Figs. 1] and [3])[13] [16] between June 2017 and January 2022 were enrolled. Patients who did not undergo postoperative computed tomography angiography (CTA) and those who had previously undergone a pterional craniotomy were excluded. The preservation of the fSTA was defined as the continued existence of the distal segment of the fSTA (ascending frontal artery).[20] This was identified on postoperative CTA, where it could be seen distal to the edge of the skin incision ([Fig. 3]). The preservation of the pSTA was also assessed.

Zoom
Fig. 3 Modified transbasal bifrontal craniotomy. (A) Computed tomography angiography image, showing the skull flap, the temporal line (dashed white line), the supraorbital foramen (arrow), and the skin incision (staple line). (B) Intraoperative image taken after elevation of the craniotomy flap. The scalp flap (blue arrow), pericranial flap (black arrow), temporalis muscle (yellow arrow), temporal line (dashed white line), and frontal sinus (arrowhead) are visible in the image.

Operative Technique

Using a scalpel, the modified bicoronal incision was begun just posterior to the temporal peak on both sides and extended just posterior to the hairline toward the widow peak ([Fig. 2]). Doppler ultrasonography was not utilized during the operation. A two-layer technique was used to separate the scalp flap from the underlying pericranium with suprafascial dissection.[21] [22] The scalp flap was reflected inferiorly to the superior orbital rims, with preservation of the supratrochlear and supraorbital neurovascular bundles. After elevation of the pericranium, the modified transbasal bifrontal craniotomy[9] was performed ([Fig. 3]).[13] [14] [15] [16]


 

 

Results

In our study of 16 sides of cadaveric heads, the mSTA and fSTA were identified in all 16 (100%) specimens; however, no pSTA was seen in one (6.25%). The mean distance from the STA bifurcation to the zygomatic arch was 3 (1.5–4.5) cm. The most anterior part of the fSTA passed through the temporal peak in 2 specimens (12.5%), passed anterior to the temporal peak in 9 (56.25%) specimens, and passed posterior to the temporal peak in the remaining 5 (31.25%) specimens ([Table 1]). The average distance from the fSTA to the temporal peak in the anterior and posterior aspects was 0.44 (0.2–0.7) cm and 0.52 (0.3–0.8) cm, respectively ([Table 2] and [Fig. 4]).

Table 1

The results of cadaveric head dissection

No.

fSTA anterior to temporal peak (cm)

STA bifurcation to zygomatic arch (cm)

1

−0.5

4.5

2

−0.8

3

3

0.4

3

4

0.4

2.5

5

0.2

3.5

6

−0.5

1.5

7

0.5

3

8

0.5

2.2

9

0.5

3.5

10

0

4.5

11

0

4

12

0.4

–

13

0.4

3.4

14

−0.3

2.7

15

−0.5

2.2

16

0.7

2

Average

–

3

Abbreviations: -: no parietal branch of STA; fSTA, frontal branch of superficial temporal artery; STA, superficial temporal artery.


Table 2

The relationship between the most anterior part of the frontal branch of superficial temporal artery and the temporal peak

fSTA

Anterior to TP

Through TP

Posterior to TP

Number

9 (56.25%)

2 (12.5%)

5 (31.25%)

Range (cm)

0.2–0.7

–

0.3–0.8

Average (cm)

0.44

–

0.52

Abbreviations: fSTA, frontal branch of superficial temporal artery; TP, temporal peak.


Zoom
Fig. 4 The results of our cadaveric study of the course of the fSTA. The blue dot represents the temporal peak, the solid white line represents the hairline, and the dashed white line represents the superior border of the zygomatic arch. fSTA, frontal branch of the STA; mSTA, main trunk of the STA; pSTA, parietal branch of the STA; STA, superficial temporal artery.

The sample in our clinical study comprised 19 patients who underwent clipping via IHA for AcoA aneurysms using a modified bicoronal incision. Of these patients, 9 (47.4%) were male and 10 (52.6%) were female. The average age was 56.9 (30–82) years. In 16 (84.2%) of the patients, subarachnoid hemorrhage was the presenting symptom. Our evaluation of the postoperative CTAs found that the right fSTA was preserved in 14 (73.7%) patients and the left fSTA in 16 (84.2%) patients. The overall rate of fSTA preservation was 78.9% (30/38). In 13 (68.4%) of the patients, both fSTAs were preserved. The pSTA was preserved in all patients (100%) ([Tables 3] & [4]). Frontalis paralysis was not observed in any patient.

Table 3

The characteristics of patients and the preservation of the frontal branch of superficial temporal artery after modified bicoronal incision

Case no.

Age (y), gender

Rupture

Frontal branch of STA

Parietal branch of STA

Preoperative CTA

Postoperative CTA

Preoperative CTA

Postoperative CTA

R

L

R

L

R

L

R

L

1

82, F

Y

Y

Y

Y

Y

Y

Y

Y

Y

2

53, F

Y

Y

Y

Y

N

Y

Y

Y

Y

3

57, M

Y

Y

Y

Y

Y

Y

Y

Y

Y

4

60, F

Y

Y

Y

Y

Y

Y

Y

Y

Y

5

30, M

Y

Y

Y

Y

Y

Y

Y

Y

Y

6

64, M

Y

Y

Y

Y

Y

Y

Y

Y

Y

7

63, F

N

Y

Y

Y

Y

Y

Y

Y

Y

8

62, M

Y

Y

Y

Y

Y

Y

Y

Y

Y

9

65, F

N

Y

Y

Y

Y

Y

Y

Y

Y

10

40, M

Y

Y

Y

N

Y

Y

Y

Y

Y

11

69, M

Y

Y

Y

N

N

Y

Y

Y

Y

12

40, M

Y

Y

Y

N

Y

Y

Y

Y

Y

13

57, F

Y

Y

Y

Y

Y

Y

Y

Y

Y

14

52, F

Y

Y

Y

Y

Y

Y

Y

Y

Y

15

67, F

N

Y

Y

Y

Y

Y

Y

Y

Y

16

60, F

Y

Y

Y

N

Y

Y

Y

Y

Y

17

66, F

Y

Y

Y

N

N

Y

Y

Y

Y

18

43, M

Y

Y

Y

Y

Y

Y

Y

Y

Y

19

52, M

Y

Y

Y

Y

Y

Y

Y

Y

Y

Abbreviations: CTA, computed tomography angiography; F, female; L, left side; M, male; N, no; R, right side; STA, superficial temporal artery; Y, yes.


Table 4

The preservation of the frontal branch of superficial temporal artery after modified bicoronal incision

Preservation of fSTA

Right side (n = 19)

Left side (n = 19)

Both side (n = 19)

Average

(n = 38)

14 (73.7%)

16 (84.2%)

13 (68.4%)

30 (78.9%)

Abbreviation: fSTA, frontal branch of superficial temporal artery.


[Figs. 3] and [4] present cases 9 and 10, respectively, as illustrative examples. While both sides of the fSTA were preserved in case 9 ([Fig. 5]), the incision caused the loss of the right fSTA in case 10 ([Fig. 6]).

Zoom
Fig. 5 Illustrative case (case 9). (A, B) Preoperative CTA images showing both sides of the fSTA and the ascending frontal artery (arrow). (C, D) The modified bicoronal incision is represented by the line of staples. The preservation of the fSTA on both sides was confirmed through the identification of the ascending frontal artery (arrow) on the postoperative CTA. CTA, computed tomography angiography; fSTA, frontal branch of the superficial temporal artery.
Zoom
Fig. 6 Illustrative case (case 10). (A, B) Preoperative CTA images showing both sides of the fSTA and the ascending frontal artery (arrow). (C, D) The modified bicoronal incision is represented by the line of staples. The preservation of the left fSTA and the sacrifice of the right fSTA were confirmed through the identification of the ascending frontal artery (arrow) on the postoperative CTA. CTA, computed tomography angiography; fSTA, frontal branch of the superficial temporal artery.

 

Discussion

Blood Supply to the Frontal Scalp and Bicoronal Scalp Flap

The fSTA, supraorbital artery, and supratrochlear artery provide blood supply to the forehead area of the scalp. After classic bicoronal incisions, which frequently sacrifice the STA, the bilateral supratrochlear and supraorbital arteries are often left to provide the entire scalp flap blood supply and must be preserved during scalp flap elevation.[23] [24] Because of this, there is a risk of ischemia in the bicoronal scalp flap when the STA is sacrificed. The preservation of the STA provides a better blood supply to the scalp flap, especially in cases where the supratrochlear and supraorbital arteries are absent or injured. It is also possible that STA preservation would reduce postoperative scalp complications but further research is needed to compare the rates of such complications in those with and without postoperative STA preservation.


 

Previous Anatomic Studies of the STA

Studies of the anatomy of the STA have contributed various insights. Tayfur et al studied 33 cadaveric heads and found that the STA bifurcation was located above the zygomatic arch in 62%. The mean distance between the STA bifurcation and the superior border of the zygomatic arch was 2.3 cm.[25] Jean-Philippe et al used the head and neck CTA of a patient sample to study the STA. They found that the length of the fSTA ranged from 23 to 101 mm, with a mean of 58 mm. Its angle in relation to the oculo-meatal line ranged from 0 to 60 degrees, with a mean of 28 degrees. The STA bifurcation was located above the zygomatic arch in 61.54% and was nearly located above the oculo-meatal line in 99.04%. The distance between the STA bifurcation and the zygomatic arch ranged from 0 to 47 mm, with a mean of 12 mm.[17]

Pinar and Govsa studied the anatomy of the STA in 27 sides of cadaveric heads. The fSTA was present in all of their specimens and ran forward to the front of the head, parallel with the upper corner of the orbicularis oculi muscle. It then returned to the galea to supply blood to the frontalis muscle. The diameter of the fSTA was greater than that of the pSTA in 55% of their specimens.[19] Tubbs et al studied the STA anatomy of cadaveric heads in relation to deeper brain structures. They found the STA bifurcation to be located an average of 3 cm superior to the tragus. Many deep brain structures could be identified using the branches of the STA, but the courses of these branches should first be confirmed by palpation or Doppler identification.[26] Kim et al used three-dimensional CTA to study the anatomy of the STA. Three landmarks (the posterior margin of the mandible condyle, the superior margin of the zygomatic arch, and the keyhole) were used as reference points for localization of the STA bifurcation. They found that 82.6% of STA bifurcations occur above the zygomatic arch at a mean distance of 21.7 mm.[27]

Koziej et al studied 419 STAs on head CTAs. They found a mean distance between the lateral angle of the orbital rim and the fSTA of 36.6 mm. Frontal and parietal branches were detected in 98.1 and 90.7% of patients, respectively. The STA bifurcation was located above the zygomatic arch in 75.6%, below in 14.7%, and on the zygomatic arch in 9.7%. The mean distance from the center of the zygomatic arch to the STA bifurcation was 16.8 mm.[18] In a meta-analysis of STA morphology, the STA bifurcation was located above and on the zygomatic arch in 79.1 and 11.1% of instances, respectively. The frontal and parietal branches of the STA were present in 97.6 and 96.4%, respectively. The fSTA was found to have a significantly larger mean diameter than the pSTA, suggesting that the fSTA is the main branch.[28]

Kleintjes determined the lateral orbital rim to be the key visible or palpable landmark required to predict the course of the fSTA. The fSTA was present in 70% of their specimens and coursed anterosuperiorly from the temporal area to the forehead, turning superoposteriorly at an acute angle from the forehead as the ascending frontal artery or transverse frontal artery neared the lateral orbital rim. However, the exact location of this fSTA turning point is not well described in their study.[20]

Despite these previous anatomical studies, the anatomical landmarks of the fSTA have not been established. Our cadaveric study demonstrated the close relationship between the most anterior part of the fSTA and the temporal peak. All of the fSTA passed just anterior or posterior (within 0.5 cm) to the temporal peak.


 

The Risk of STA Injury Using the Modified Bicoronal Incision

The traditional bicoronal incision resembles the pterional incision, which is performed on both sides of the skull. Suanchan et al[11] found that standard pterional incisions pose a significant risk of injury to the STA, particularly affecting the pSTA. Consequently, the risk of vascular injury is also substantial with the classic bicoronal incision.

Previous anatomical studies of the STA have shown that the majority of the fSTA follows a path that is close to the oculo-meatal line in the temporal region. It then extends forward toward the forehead, running parallel to the upper edge of the orbicularis oculi muscle.[17] [19] [20] Consequently, employing a modified bicoronal incision may pose a risk of injury to the STA, particularly concerning the fSTA.

There have been no previous clinical studies of the preservation of the STA after modified bicoronal incisions. Our clinical study showed a high rate of fSTA preservation (78.9%) and 100% rate of pSTA preservation after modified bicoronal incisions. This was in accordance with our cadaveric finding that the majority of fSTAs (68.75%) pass through and just anterior to the temporal peak.


 

The Risk of Facial Nerve Injury Using the Modified Bicoronal Incision

Shin et al studied 55 sides of cadaveric heads and found that the temporal branch of the facial nerve (TFN) generally courses 1 to 2 cm anteriorly and inferiorly to the fSTA in the temporal region. However, in 3.6% of their specimens, the TFN ran just beneath the fSTA.[29] This study found that a scalp incision on or anteroinferior to the fSTA risks injury to the TFN. To avoid this, the incision should be superior and posterior to the fSTA. Because the majority of fSTAs passes through and just anterior to the temporal peak and the modified bicoronal incision begins just posterior to the temporal peak, the risk of TFN injury using this incision is low.


 

Limitations of the Modified Bicoronal Incision

The traditional or classic bicoronal flap provides critical exposure of the maxillofacial area with an aesthetic outcome.[5] [23] [24] In the modified bicoronal incision, the skin incision is shorter and a smaller area of bone exposure is required. This modified incision provided adequate exposure for the modified transbasal bifrontal craniotomy, allowing access to the anterior and inferior surfaces of the frontal lobe, the anterior skull base, and the frontal air sinuses. Since the inferior limit of exposure using the modified incision is the superior orbital rim, inferior access to the maxillofacial area is not possible. This limitation can be corrected by extension of the incision inferior to the temporal peak along the hairline, but the fSTA is then frequently transected. The lateral limit of this incision is just lateral to the temporal line. When temporal lobe or lateral frontal lobe access is needed, the classic bicoronal incision is necessary.


 

Complications of Bicoronal Incisions

Long-term alopecia has been reported as a postoperative complication of 7 to 18% of bicoronal incisions. The risk factors found to contribute to this complication were the use of a Raney clip for a prolonged period to control bleeding and Colorado tip monopolar cautery of cutaneous and subcutaneous incisions.[2]

Although postoperative alopecia was not assessed in the present study, we routinely use Raney clips and cold steel scalpel for cutaneous and subcutaneous incisions. This is because the likelihood of this complication is not expected to be high with modified bicoronal incisions as the incision is performed just behind the hairline and the high preservation rates of the STA and the supraorbital and supratrochlear arteries suggest a robust blood supply to the scalp flap. Nevertheless, this issue should be studied further in the future.


 

Strength and Limitations of Our Study

The retrospective and descriptive nature of our study was its main limitations. The relatively small numbers of cadavers and patients were also drawbacks. The clinical outcomes, such as scalp flap ischemia, delayed wound healing, wound infection, and alopecia, were not assessed in this series. However, it can be assumed that these complications should be minimized when the arterial supply is preserved to the greatest extent possible.

To the best of our knowledge, this is the first study to simplify the localization of the fSTA during surgery through the determination of its location in relation to the hairline.


 

 

Conclusion

The most anterior part of the fSTA was located very close to the temporal peak of the hairline. The modified bicoronal skin incision for bifrontal craniotomy and modified transbasal craniotomy was an effective means of STA preservation.


 

 

Conflict of Interest

None declared.


Address for correspondence

Kitiporn Sriamornrattanakul, MD
Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University
Bangkok 10300
Thailand   

Publication History

Article published online:
26 June 2025

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  Permissions and Reprints
Zoom
Fig. 1 Classic (dashed white line) and modified (dashed yellow line) bicoronal incisions. The classic incision begins just above the zygomatic arch and curves slightly anteriorly at the midline to meet the same point above the opposite zygomatic arch. The modified incision begins just posterior to the temporal peak (red arrow) on both sides and extends just posterior to the hairline (black line) toward the widow peak (blue arrow).
Zoom
Fig. 2 The relationship between the most anterior part of the fSTA and the temporal peak. (A) The hairline (white line), temporal peak (yellow dot), widow peak (black arrow), and sideburn (blue arrow) were identified. The red lines show the courses of the mSTA, fSTA, and pSTA. The distances between the most anterior part of the fSTA and the temporal peak (a) were measured. (B) After the skin was reflected through the subcutaneous plane, the temporal peak (yellow dot) was marked and the fSTA (dashed red line), pSTA, and mSTA were dissected. The distances between the most anterior part of the fSTA and the temporal peak (a) and between the STA bifurcation and the zygomatic arch (b) were measured. fSTA, frontal branch of the STA; mSTA, main trunk of the STA; pSTA, parietal branch of the STA; STA, superficial temporal artery.
Zoom
Fig. 3 Modified transbasal bifrontal craniotomy. (A) Computed tomography angiography image, showing the skull flap, the temporal line (dashed white line), the supraorbital foramen (arrow), and the skin incision (staple line). (B) Intraoperative image taken after elevation of the craniotomy flap. The scalp flap (blue arrow), pericranial flap (black arrow), temporalis muscle (yellow arrow), temporal line (dashed white line), and frontal sinus (arrowhead) are visible in the image.
Zoom
Fig. 4 The results of our cadaveric study of the course of the fSTA. The blue dot represents the temporal peak, the solid white line represents the hairline, and the dashed white line represents the superior border of the zygomatic arch. fSTA, frontal branch of the STA; mSTA, main trunk of the STA; pSTA, parietal branch of the STA; STA, superficial temporal artery.
Zoom
Fig. 5 Illustrative case (case 9). (A, B) Preoperative CTA images showing both sides of the fSTA and the ascending frontal artery (arrow). (C, D) The modified bicoronal incision is represented by the line of staples. The preservation of the fSTA on both sides was confirmed through the identification of the ascending frontal artery (arrow) on the postoperative CTA. CTA, computed tomography angiography; fSTA, frontal branch of the superficial temporal artery.
Zoom
Fig. 6 Illustrative case (case 10). (A, B) Preoperative CTA images showing both sides of the fSTA and the ascending frontal artery (arrow). (C, D) The modified bicoronal incision is represented by the line of staples. The preservation of the left fSTA and the sacrifice of the right fSTA were confirmed through the identification of the ascending frontal artery (arrow) on the postoperative CTA. CTA, computed tomography angiography; fSTA, frontal branch of the superficial temporal artery.