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Posts Tagged ‘temporal artery ligation’

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.

Highlights:

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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