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Prominent ‘veins’ or ‘worms’ that cross from the temples into the forehead are neither….they are arteries… specifically the anterior branch of the superficial temporal artery. This enlarged branch of the superficial temporal artery occurs almost exclusively in men presumably because of the thicker muscle layer in the  arterial walls of a male. Why it gets enlarged to the point that it becomes unaesthetically visible in certain men however is far less clear. It is known what makes it become visible (e.g., exercise, alcohol, heat) but why it does so is not known.

In the treatment of the prominent anterior branch of the superficial temporal artery it has been my experience that it requires a multilevel ligation approach. This always requires at least three levels and sometimes four. One would think that tying off the artery at its proximal branching point (at the Y)  in the temporal region and then at its most  distal point just before it enters the scalp would be enough. Shutting off the inflow and the backflow points should be sufficient …but it rarely is. One will find that pulsations will still exist between them at the open forehead area usually at along the bony temporal line region.

A critical ligation point then is at this open exposed forehead ares. This is another branching point where the artery turns almost at 90 degrees towards the frontal hairline, suggesting another point of inflow not easily seen. Which also explains why a proximal and distal ligation points alone doesn’t completely shut off the blood flow.

This requires a small 5mm incision on the exposed forehead which should be placed in a horizontal orientation based on natural forehead wrinkle lines when raising one’s eyebrows. Unlike any of the other ligation points what differentiates this one is the proximity of the frontal branch of the facial nerve. As a result it is important to carefully isolate the artery and extract it outward before ligating it to ensure that the small nerve branch does not accidentally become ligated also.

When these ligation points are completely it is important to check for any residual blood flow by either doppler or palpable pulsations. There should be no pulsations present at the end of these ligations. If it still exists (and sometimes it does) than additional ligation point is needed.  

Dr. Barry Eppley

Indianapolis, Indiana

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