Background: The superficial temporal artery (STA) is one of numerous blood supplies to the top of the head and scalp. Emanating off of the external carotid artery in the neck the origin of this arterial branch courses in front of the ear where its ascends into the temporal region and splits into anterior and posterior branches. The anterior branch then crosses into the exposed forehead before making an almost 90 degree turn up into the scalp.
Why temporal arteries become more prominent in some individuals is not known. It does occur much more frequently in men than women and is more likely to occur in thinner patients with some temporal concavities/hollowing. In a few patients there are obvious explanations such as weight loss and aging where thinning of subcutaneous tissue thickness exposes the arterial pathway in the temporal and side of the forehead. It is also unknown why this end arterial branch has such a serpiginous pattern as it crosses into the forehead. (the artery leading up to it does not) There has to be a biologic reason for such a pattern but to date I have not thought or heard of a good explanation for it.
What is better known are the triggers that make the STA more prominent. Exercise, heat and alcohol are well known to do so. An elevated heart rate and subsequent increased blood flow are obvious triggers. Heat understandably causes the more superficial arteries to dilate by either smooth muscle relaxation, the need to release heat or both. The influence of alcohol on muscle relaxation is also well known but it is n to a direct one. Alcohol is a central nervous system depressant which secondarily causes peripheral muscle relaxation…of all muscles. The STA just happens to be an easily observable one due to its superficial location.
Case Study: This young male had developed prominent temporal arteries for no apparent reason. They became more pronounced with known triggers such as exercise and heat but alcohol caused them to become the most pronounced. In particular beer, especially IPAs, really caused them to become noticeable. The artery was more pronounced on the right than the left. The vessel’s had the classic serpiginous pattern with a very palpable pulse at all visible areas. Four ligation points were marked on each side.
To create the greatest arterial prominences before the procedure, he was asked to drink several beers to make them the most visible. Under local anesthesia all four ligation points were opened, the artery dissected out through the incision and double 5-0 prolene sutures used to tie it off.
On the right side a positive doppler signal was still persistent and a fifth ligation done down by the front of the ear to finally eliminate the doppler signal.
The final procedure consisted of five ligations on the right side and four ligations on the left side to fully eliminate the doppler signal along each arterial pathway.
The concept of multi-level ligation to shut off the flow of the anterior branch of the superficial temporal artery is conceptually straightforward but tedious and exacting to perform. Eliminating inflow and back flow is the objective but very often it is not just one single arterial pathway. If it were a single proximal and distal ligation point would be suffice…but it never is. In many patients there is an ancillary branch that takes off in front go the ear before the main trunk of the STA ascends in to the lower temporal region. While anatomic diagrams show it does not connect to the STA system that is not anatomically accurate.
Case Highlights:
1) The reason for prominent temporal arteries is not known but there are some known triggers…in this case beer was the most prominent initiator.
2) Multi-level ligations are required to reduce the appearance of prominent temporal arteries, usually four on each side is required.
3) In refractory cases that fail a negative doppler sign it may be necessary to ligate the main trunk of the artery at the sideburn area in front of the ear.
Dr. Barry Eppley
World-Renowned Plastic Surgeon