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Archive for the ‘temporal artery ligation’ Category

Technical Strategies – Mapping the Multipoint Temporal Artery Ligations

Sunday, November 26th, 2017


The superficial temporal artery (STA) is a branch of the facial artery  that crosses in front of the ear and heads northward into the scalp. At a fairly predictable point above the ear it turns into a Y configuration with an anterior branches coursing across the forehead at it turns up into the scalp. It has a very snake-like course along this pattern much like many rivers going through a valley. It is not precisely known why it has this very irregular course when a straighter line would presumably suffice but there is undoubtably some developmental purpose to it.

For reasons that are equally unclear as that of its sinuous course, in some people the course of the artery becomes very apparent due to vessel dilatation. This appears to be almost exclusively in men which I assume is due to their large muscle component of the arterial walls. When exposed to any agent that causes the artery to experience increased flow, such as heat, exercise and alcohol being the common offenders, it bulges out like a thick rope producing a unique and unaesthetic feature of the temples and forehead. In men with hair the dilated artery and its dicta branches are only seen beyond the hairline. But in men who shave their heads or with very short hair, the course of the abnormal vessel may be seen all up along the ear and into the forehead.

The surgical treatment for a prominent STA is ligation. While it is tempting to do so only in a most proximal location, this approach should be avoided. While I have seen cases of that being done and the patient reports some reduction in its prominence, it is not usually completely successful strategy. This is because, while all veins have valves, few arteries do. This allows the high potential for backflow coming across the scalp and back down into the distal portion of the arterial system allowing the vessel to remain prominent. This serves as the basis for a multipoint ligation approach.

In this temporal artery ligation technique, the course of the prominent STA is marked out and a proximal and two or three distal ligation points are marked. The distal locations are either at branch points or linear backflow points  in the forehead and are placed in a horizontal skin crease so that the small incisions can heal in an undetectable manner.

What this temporal artery ligations approach, the success rate is higher with a much lower revision rate. There have been no instances of facial nerve injury or scalp hair loss issues.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Multi-Point Temporal Artery Ligation

Thursday, August 17th, 2017


The development of visible temporal arteries in the forehead is not rare. Occurring almost exclusively in men, the frontal or anterior branch of the superficial temporal artery becomes dilated and its course up into the forehead becomes prominent. Often occurring after exercise, heat exposure or alcohol intake, the muscular walls if the artery dilate makes its course very visible. In some patients the size of the artery may decrease but in other patients it may persist for days. While this is largely as aesthetic issue, some patients complain of associated headaches and even visual blurring.

Temporal artery ligation is the surgical treatment for such aesthetic forehead vessel dilatations. It should be not confused, however, with the ligation technique done for temporal arteritis or temporal artery biopsy. While that procedure does ligate (and remove a section) of the vessel, its intent is not to stop the flow through the artery. It is to remove a section of the vessel for pathologic analysis. Any blood flow reduction is an inadvertent side effect.

But aesthetic temporal artery ligation is done with the intent of ceasing flow through the prominent section of the artery. If flood is diminished or eliminated it will no longer be visible. While it may seem like ligating the vessel before it ever enters the non-hair bearing temporal and forehead areas should work, it often by itself does not. This only treats one part of the problem, inflow or anterograde flow. It does not account for back flow or retrograde flow which comes from the cross-connections across the scalp.

The real key to the procedure is to carefully trace the pattern of the vessel forward and look for branching points. At these identified branching points ligations must be done to cut off back flow once forward flow is eliminated. This can be difficult to always completely identify as the artery has a very tortuous pattern in the forehead. Sometimes they are visible but many times it requires careful palpation to find them.

The number of temporal artery ligations points will vary for each patient but can range from two to seven. The average number is three per side. Men who shave the head or have closely cropped hair often undergo more ligation points due to greater vessel exposure along its length. In the forehead area it is also important to place the small incisions in natural skin wrinkle lines which can be found by having the patient raise their eyebrows.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Temporal Artery Ligation

Wednesday, May 3rd, 2017


Temporal artery ligation is traditionally a medical procedure done as a diagnostic procedure for temporal arteritis. In this procedure it is done at the edge of the temporal hairline through a cm. or large incision in which a section of the artery is removed and sent to pathology for histologic examination. Technically this procedure should be called temporal artery biopsy, two end ligation is a necessary part of the procedure but not its main intent.

Conversely, true temporal artery ligation is a cosmetic procedure to specifically reduce the flow in the superficial temporal artery system and lessen or eliminate the prominent appearance of the vessels. This procedure does not remove a section of the artery nor is it necessary to do so to have its aesthetic effects. Rather it lies on point ligation of inflow and back flow points that contribute to inflow into the prominent vessel.

Temporal artery ligation first requires a precise mapping of the prominent vessel and any back flow points. An anterograde and retrograde ligation point should be initially marked. On any single vessel at least two points of ligation will be needed. This is done by digital palpation or an ultrasound doppler can be used. In some cases the path of the vessel is visible evident. But this is usually less evident as the vessel takes a tortuous course out into the forehead. In most cases at least one ligation point will be needed on the forehead which is always placed in a horizontal wrinkle line.

Unlike temporal artery biopsy, the size of the incision in temporal artery ligation is much smaller. It usually is no bigger than 5mm or 6mms. The artery is located and often teased out of the incision where a double ligation with a small permanent suture is used. (5-0) The incisions are closed with small resorbable sutures. (6-0)

Dr. Barry Eppley

Indianapolis, Indiana

The Anatomy of Aesthetic Temporal Artery Ligation

Sunday, March 12th, 2017


Temporal artery ligation has been a surgical procedure done for decades. It has been historically used as a medical procedure to diagnose temporal arteritis as a biopsy technique. In this operation a section of the anterior branch of the superficial temporal artery is removed behind the front edge of the temporal hairline.

More recently, temporal artery ligation is being done for aesthetic purposes. Almost always men, prominent or protruding arterial patterns from the temporal area up onto the forehead can be seen as an aesthetic liability. These vessels can become quite large as they dilate from exercise, heat and alcohol intake. While such temporal artery prominences can occur in women, they appear to occur far less frequently. This may be due to hormonal differences but also in the differing thicknesses of the muscular walls between the genders.

Superficial Temporal Artery Anatomy Dr Barry Eppley IndianapolisThe aesthetic treatment of prominent temporal arteries requires a dynamic knowledge of the anatomy of the superficial temporal artery. (STA) The STA arises from the external carotid artery where it courses in front of the ear towards the temporal region. As it passes the ear and into the temporal hairline it splits into a Y about at a point 1 cm anterior to the root of the ear and the 2 cms above that point. The frontal or anterior branch of the STA is what extends into the forehead and is the source of vessel prominence.

In looking at its anatomy, two observations are extremely relevant when considering ligation for aesthetic reduction in its size. First, the anterior branch turns into numerous smaller arteries whose patterns are both tortuous and unpredictable as it goes into the forehead. Thus what one sees as prominent is often an incomplete reveal of the complete arterial branching pattern. Secondly, there is a vast anastomotic pattern into the scalp with numerous interconnections between them. This means that the consideration of backflow must be factored into the location and number of ligation points.

The anatomy of the STA shows that simply tying off the main trunk of the STA will not likely work and, even if it does, its results will likely be temporary. Blood flow through the numerous superior branches will find its way back down and the vessels again. The first ligation point must be just after the take-off at the Y junction. Then one, two or three more distal ligations points must be done in an effort to cut off the backflow into the visible vessels. These can be determined by either their visibility or palpabiity. Sometimes they are not easy to initially locate but one had to look for them as they are the key to  a successful long-term result.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Aesthetic Temporal Artery Ligations

Saturday, December 31st, 2016


Prominent bulges in the temporal region are almost always caused by the temporal arteries. The superficial temporal artery comes off the facial artery in the neck and courses upward in front of the ear. Once it reaches a typical landmark point of 1 cm in front of the ear and 2 cms about that point, it bifurcates in to a Y pattern. The front part of this takeoff is the anterior branch of the superficial temporal artery and it continues towards the forehead in a very tortuous pattern.

This anterior branch of the temporal artery is fairly superficial and is prone to becoming visibly enlarged. Why it does so is not precisely known but it occurs far more commonly in men. (although it does occur in women as well) It can become quite noticeable with exercise, heat, alcohol intake and a low head position.  It can sometimes be associated with temporal headaches as well.

When the procedure of temporal artery ligation is considered, what is done for prominent temporal arteries is quite different than the historic approach of simple ligation. The original temporal ligation procedure, also known as a temporal artery biopsy, was done to diagnose arteritis or autoimmune conditions. This is where an incision was made behind the temporal hairline and a section of the artery is removed. This is a single incision which is fairly large by aesthetic standards.

temporal-artery-ligation-dr-barry-eppley-indianapolisThe aesthetic temporal artery ligation procedure is a multi-incisional technique that strategically places ligation points at select points along the course of the artery into the forehead. This is always at least two points and often three. These are very small incisions that take into account the wrinkle lines of the forehead when placed in that location. They heal exceptionally well and leave little to no trace of a scar.

Dr. Barry Eppley

Indianapolis, Indiana

The Ladder Technique in Temporal Artery Ligation

Sunday, June 26th, 2016


Unaesthetic bulging vessels in the temporal region at the side of the forehead are caused by the anterior branch of the superficial temporal artery. Why it gets enlarged is not precisely known although it appears to occur almost exclusively in men. Its enlargement is clearly related to increased blood flow as the vessel becomes most symptomatic with exercise, heat and alcohol intake.

superficial temporal arteryTreatment of prominent temporal vessels can be done by a temporal artery ligation procedure. It would seem logical that if the most proximal portion of the temporal artery were tied off that would provide an immediate solution to the problem by reducing inflow into the vessel. But it is not quite that simple. The anterior branch of the superficial temporal artery has a tortuous course and may have more than one inflow branch into it as it ascends into upper forehead. Anatomic drawings of the vascular patterns of the face are not always accurate or as consistent as they appear.

Right Temporal Artery Ligation Dr Barry Eppley IndianapolisLeft Temporal Artery Ligation Dr Barry Eppley IndianapolisTo get the best reduction of the temporal artery prominence it usually requires more than one ligation point. This is usually two or often times three ligation points are needed. This has led to the ‘ladder technique’ for temporal artery ligation. Beginning at the anterior edge of the side burn, three ascending points of ligation are used with only one in the more visible forehead region located in a wrinkle line.

The ligation points are all exposed and the sutures placed around them but none of them are tied. Then in a descending fashion the sutures are tied down as the blood in the vessels is digitally forced out of the vessel in a retrograde fashion. This allows the vessels to hopefully collapse as they are tied.

Temporal Artery LIgation result Dr Barry Eplpey IndianapolisThe ladder technique of temporal artery ligation is the treatment method that I have evolved to having done the procedure over several years. It has a high rate of success with significant reduction or elimination of the prominent temporal artery branch.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Facial Artery Ligation for Prominent Pulsations

Wednesday, June 22nd, 2016


Background: Prominent blood vessels on the face, while common, are not usually a source of cosmetic concern. By far the most common location of blood vessel visibility is in the forehead. Prominent arteries in the temporal region and side of the forehead as well as more central forehead veins can be seen in both men and women. Ligation of these vessel prominences is the preferred treatment.

Almost all of the prominent blood vessels that I have seen in my practice have been in the temporal region. But in rare cases I have seen it occur in the perioral region either on the side of the mouth or in the lips. These are branches of the facial artery whose symptoms are visible pulsations in one discrete spot and feeling of enlargement/prominence.

facial arteryThe facial artery comes off of the external carotid artery below the jaw. It crosses the jaw over the midportion of its body and extends upward towards the corner of the mouth. Form this point it ends up to the side of the nose and the inner eye area where it is known as the angular artery. It sends off branches at the corners of the mouth to the lip known as the labial arteries. The facial artery is rather tortuous to accommodate a wide range of facial movements. It’s tortuous nature and the branch pattern at the corner of the mouth can create a loop of the facial artery which can develop a pulsatile pattern due to its looped shape.

Case Study: This 33 year-old male had a prominent and bothersome vessel located just to the left side of his mouth. It could be seen to be in one spot about 2 cms lateral to the corner of the mouth with a very visible pulsation pattern. The pulsations could be seen but not the actual vessel.

Under local anesthesia, an 8mm skin incision was made in a skin crease that was determined when he smiled. Careful dissection revealed several very superficial branches as well as a deeper loop. All were double ligated with permanent 5-0 sutures, for a total of four specific ligation sites.

With the tying down of the ligatures, there was an immediate reduction in the size and visibility of the arterial pulsations. While there has to be an immediate effect with arterial ligation, the real test is what it is like three to six months after the surgery. Presumably in facial artery ligation of a prominent loop, secondary vessel ligation or inflow recruitment does not occur.


1) Certain arteries on the face can be aesthetically disturbing due to their visibility with the most common being the temporal arteries in men.

2) A very uncommon aesthetic artery disturbance is that of the facial artery where it crosses onto the face at the level of the mouth.

3) Ligation of the pulsatile region of the facial artery can be done through a small overlying incision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Temporal Artery Ligation

Monday, May 23rd, 2016


Background: The superficial temporal artery is a branch of the external carotid artery. It runs up along the back line of the lower jaw and curves anteriorly where it crosses teh back part of the zygomatic arch at its junction with the temporal bone. Once it crosses the  zygomatic arch, it splits into a Y into two divides in two terminal branches. The anterior branch, also called the frontal branch, ascend obliquely across the upper temporal region into the forehead. The posterior branch, also called the parietal branch, courses posteriorly above the ear.

The frontal branch of the superficial temporal artery is prone to develop extreme visibility in some people which they find bothersome. The reasons why it does so are not clear. I have only seen it in men and have never received a concern about its appearance from women. The typical symptoms are that it can not be present at all or slightly present at ‘rest’ but numerous activities make the pathway of the vessel dilate and become very prominent. Such activities includes exercise, heat, excitability, and drinking alcohol.

Treatment of the prominent anterior branch of the superficial temporal artery is by surgical ligation.While ligating the takeoff of the anterior branch would seem a logical approach, there is always the issue of backflow into it which would still leave it prominent. Thus at least a two point ligation should be done with the distal point on the forehead before it branches and goes into the frontal hairline.

Temporal Artery LIgation mapping Dr Barry Eppley IndianapolisCase Study: This middle-aged male had visible anterior branches of the superficial temporal artery at rest on both sides of his temples. These became more so with increased activity and heat. Their irregular course was clearly visible from the edge of the temporal hairline up into the forehead. Their wavy irregular course, which is common, was clearly seen and marked.

Right Temporal Artery LIgation immediate result Dr Barry Eppley IndianapolisLeft Temporal Artery LIgation immediate result Dr Barry Eppley IndianapolisUnder local anesthesia small incisions (6mms) were made just inside the temporal hairline and at the end of an upper forehead wrinkle just below the frontal hairline on both sides. Double ligations were performed in all four areas with 5-0 prolene suture. While the palpable inflow was immediately reduced (pulsations were no longer felt), the prominent of the vessels initially remained. With further observation they did reduce somewhat but an additional ligation was done along the temporal hairline area above the initial ligation point.

The success or temporal artery ligation depends on elimination of the inflow AND subsequent collapse of the vessels. Even with two ligation, which should theoretically work, the visibility of the arteries may not always be completely eliminated. Unseen feeder vessels between the two ligation points and strength of the vessel walls (they are arteries so their walls contain muscle) may cause the vessel prominence to persist although less so than before ligation.

The other issue about the success of temporal artery ligation is whether such flow can eventually return. Loss of the ligature points (which is why I double tie) and backflow dilation of any unseen takeoff branches could all be reasons for potential recurrence.


1) A prominent anterior branch of the superficial temporal artery can create an undesired aesthetic line along the sides of the forehead.

2) Two-point temporal artery ligation can reduce and, in some cases, eliminate the appearance of the temporal vessels.

3) The aesthetic success of temporal artery ligation depends on whether unseen feeders flow into the visible nerve branch and how much the artery will shrink after flow into it is eliminated.

Dr. Barry Eppley

Indianapolis, Indiana

Single Point Temporal Artery Ligation

Saturday, March 12th, 2016


Prominent temporal vessels can be a source of aesthetic concern. Looking like worms due to their serpiginous course on the sides of the forehead, they usually have an episodic appearance. When the temperature is warm, the person’s heart rate is elevated or when one bends over, the size of the vessels either become prominent or increasingly so. Prominent temporal vessels largely appear in men and only very rarely in women.

temporal artery anatomyWhile some think that these prominent temporal vessels are veins, they are in reality arteries. This is easily conformed by feeling the pulsations in them. They are always anterior branches of the superficial temporal artery system. While anatomic drawings usually show them as occurring in one consistent pattern, they present in many variations. The anterior branch may have a low takeoff from the main artery down at the sideburn level or can be much higher in the mid-temporal region.

Temporal Artery Ligation Dr Barry Eppley IndianapolisReduction of the prominent temporal artery is done by ligation. The key to a successful temporal artery ligation procedure is do clearly identify the anterograde course of the artery as well as any side branches that may flow retrograde into it afterwards. This is best done by close visual inspection and feel, pushing down on various parts of the arterial course and seeing how much it reduces its visibility.

Due to backflow from various seen and unseen branches off of the anterior branch of the temporal artery, multi-point ligation is usually needed. Placing ligation points close to whether the anterior branch comes off the superficial temporal artery as well as at its most distal point in the forehead is the best technique to prevent recurrent arterial prominence.

Temporal Arter Ligation incisions Dr Barry Eppley IndianapolisIt is uncommon to be able to do a single proximal point of ligation and reduce the prominent temporal artery completely. This single point approach has often been tried but rarely works due to backflow. But in some cases where compressing the identified proximal portion of the artery eliminates all palpable pulsations, it is reasonable to do. By placing a 5 to 7mm incision inside the temporal hairline a permanent ligation suture can be placed around it.

Dr. Barry Eppley

Indianapolis, Indiana

Temporal Artery Ligation Technique for Prominent Temporal Vessels

Tuesday, October 27th, 2015


th-1The superficial temporal artery is one of the major arteries to the scalp. Its course is well known as it arises from the external carotid artery and extends superiorly in front of the ear as it heads further north. At a point at about 2 cms above and 1cm anterior to the ear, the superficial temporal artery splits into a Y becoming the anterior and posterior temporal branches. The anterior branch heads off at about 45 degrees towards the forehead where is does so in a very tortuous and serpeginous course. While often portrayed as a single branch, other anterior temporal branches can take off below the Y juncture.

Medically the superficial temporal artery is best known as being affected by giant cell arteritis. Determining this diagnosis is the historic reason for superficial temporal artery surgery by biopsy which is, in effect, a double ligation procedure so that an intervening arterial segment can be removed. More recently the superficial temporal artery has been implicated in specific types of migraine attacks and ligation has been offered as a treatment option in select patients.

The anterior branch of the superficial tenporal artery can also have aesthetic implications as well. In some people, usually men, the artery can have considerable prominence which arises or is magnified by heat, exercise or anything that accelerates one’s heart rate. Arterial dilatation can cause a considerable prominence which can be aesthetically bothersome and is an uncommon form of temporal deformity. This appears as a very prominent vessel that arises in the non-hair bearing tenporal region to the side of the eye and extends variable distances into the forehead.

Ligation of a prominent anterior branch of the superficial temporal artery is the treatment for a prominent vessel…but it is not so simple or easy. A single point ligation at the anterior take-off will not usually work alone due to arterial back flow and unseen contributing arteries that feed into the prominent vessel. In rare cases I have done a single point ligation where the artery leaves the hairline and been successful…but that requires a fairly sort and well defined arterial branches that disappears at the anterior temporal line of the forehead. Almost always two or three point ligation is needed with the one or several of the ligation areas on the forehead. A thorough digital examination is needed before the procedure to properly map the arterial course and determine the effects of arterial flow stoppage at various points along its course.

The incisions for anterior branch superficial temporal artery ligation only need to be about 5mms in length. They need to be big enough so the artery can be dissected and hooked where a suture is passed under it for ligation. In this technique a loop of the artery is actually brought out of the incision where it is easier and safer to pass a suture under it. This also ensures that the frontal branch of the facial nerve is not inadvertently ensnared in the suture for those ligation points where the nerve may be in danger. The incisions are closed with very small sutures (6-0 plain or 7-0 chromic) and no dressings are used. These small incisions heal with virtually no scar.

Since all arteries in the body have a purpose there is always concern of what side effects could these ligations cause. Questions arise anywhere from skin necrosis of the scalp, hair loss, and compensatory dilation of other surrounding arterial vessels. None of these side effects have I yet seen or would they be likely occur. By keeping the ligation points well anterior to the bifurcation or main trunk of the anterior branch of the superficial temporal artery the zone of vessel occlusion remains as small as possible. For the sake of safety and being conservative, only treating one side at a time seems prudent.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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