Branch Of Superficial Temporal Artery Research Articles

Microscopic anatomy study of artery of auricle for auricle replantation

Objective To provide the anatomical information for auricle replantation. Methods From March, 2016 to March, 2019, a total of 25 fresh adult cadaveric head were used, 20 of these specimens were perfused with plastic and eroded to be vascular cast mold, 5 specimens perfused with red latex for anatomy, then observed the origin, course, diameter and arteries anastomose between branches of the posterior auricular artery (PAA) and superficial temporal artery (STA). Results The main blood supply to the auricle were auricle branches of PAA and STA. The auricle branches of PAA and STA both divided into superior, intermedius and inferior branches, and distributed in the auricle posterior surface and anterior surface, respectively. The auricle branches of PAA running across ear cartilage, distributed in the anterior surface, and anastomosed with auricle branches of STA. The diameters of these branches at the initiating portion were 0.2-0.8 mm. Eighty percent of blood supply to earlobe was from the inferior branches of PAA, and 20% from the STA. Conclusion The auricle branches of PAA played an important role to the auricle replantation. The auricle branches of PAA should be the firstly selected vessle in operation, and the auricle branches of STA be the second choice. Key words: Posterior auricular artery; Superficial temporal artery; Auricle replantation; Microscopic anatomy

An anatomic study of superficial temporal artery to anterior cerebral artery bypass using ipsilateral parietal branch of superficial temporal artery as graft

Objective Revascularization of the distal segment of the anterior cerebral artery (ACA) using extracranial donors requires long interposition grafts. A novel bypass procedure which uses the two main branches of the superficial temporal artery (STA) to reach the A3 segment of the anterior cerebral artery with a single skin incision was designed. Methods Ten cadaveric specimens were dissected through a single skin incision to harvest the frontal and parietal branches of the STA from June, 2017 to September, 2017. An anterior interhemispheric approach provided access to the middle internal frontal artery (MIFA). The parietal STA was used as an interposition graft between the frontal STA and MIFA. Lengths and calibers of the distal branches of STA and MIFA were measured at the anastomotic sites. All data was statistical analysis by t-test. Results The average caliber of MIFA was (1.4±0.2) mm, which matched the caliber of both frontal and parietal branches of STA. The mean distance for an end-to-side bypass from STA to MIFA was (144.5±7.4) mm and the average harvested donor-graft complex length was (203.1±27.9) mm. This bypass construct provided around 140% donor graft length. Conclusion Using the parietal branch of the STA as an interposition graft enabled a successful tension-free STA-MIFA bypass. The advantages of this technique over existing approaches include sufficient graft length, caliber match and relative technical ease. Key words: Anterior cerebral artery (ACA); Extracranial-intracranial bypass; Superficial temporal artery; Interhemispheric approach; Cerebral revascularization; Microsurgical anatomy

Non-invasive three-dimensional bone–vessel image fusion using black bone MRI based on FIESTA-C

To evaluate the image quality of bone-vessel fused volume-rendering (VR) images reconstructed by three-dimensional "black bone" magnetic resonance imaging (MRI) based on the fast imaging employing steady-state acquisition cycled phases (FIESTA-C) sequence and time-of-flight magnetic resonance angiography (TOF-MRA). Seventeen patients were analysed in this retrospective study. All patients underwent both MRI techniques including FIESTA-C and TOF-MRA and computed tomography angiography (CTA). MRI- and CT-based bone-vessel VR images were reconstructed. Visual depictions of frontal and parietal branches from the superficial temporal artery (STA) were independently scored by three experienced radiological technologists using a four-grade system. In the visual evaluation, the scores of the both right and left frontal branches in MRI-based VR image were significantly larger those at CT (p<0.01, respectively). The scores of both the right and left parietal branches tended to be larger in MRI-based than that in CT-based VR imaging, but were not significantly so (p=0.06, 0.13 respectively). In the interobserver agreement analysis, κ values were all good (range: 0.6-0.76) for STA branch evaluation in MRI-based VR images. MRI bone-vessel fused VR imaging can non-invasively depict STA frontal branches with better visibility compared to the CT-based VR imaging. This technique may be useful for the preoperative evaluation of donor branches for STA-middle cerebral artery bypass surgery.

Wound healing complications after revascularization for moyamoya vasculopathy with reference to different skin incisions

OBJECTIVEMoyamoya vasculopathy (MMV) is a steno-occlusive cerebrovascular disease that can be treated by a surgical revascularization. All the revascularization techniques influence the blood supply of the scalp, with a risk for wound healing disorders. The authors' aim was to analyze the wound healing process in the patients who underwent a direct or combined bypass surgery with a focus on different skin incisions.METHODSThe authors retrospectively identified all the patients with MMV who were treated surgically in their institution. Subsequently, they analyzed demographic data, clinical symptoms, surgical treatment, and detailed history of complications. Based on the evolution of their surgical techniques and the revascularization strategy to be used, the authors applied the following skin incisions: linear incision, curved incision, incomplete Y incision, and complete Y incision. Group comparisons regarding wound healing disorders were performed with significance testing using Fisher's exact test.RESULTSThe authors identified 172 patients with MMV (61.6% moyamoya disease, 7% unilateral moyamoya disease, 29.7% moyamoya syndrome, and 1.7% unilateral moyamoya syndrome), of whom 124 underwent bilateral operations. One-quarter of the patients were juveniles. A total of 236 hemispheres were included in the analysis, of which 27.9% were treated by a combined procedure with encephalomyosynangiosis. Overall, 5.1% major and 1.7% minor wound complications occurred. The overall wound complication rate was lower in direct revascularization compared to combined revascularization (3% vs 15.2%). The lowest incidence of wound healing disorders was found in the linear incision group for the parietal superficial temporal artery branch (1.6%), followed by the incomplete Y incision group for the frontal branch of the superficial temporal artery (3.8%) in the direct bypass group. In the combined revascularization cohort, major or minor wound disorders appeared in 14.3% and 4.8%, respectively, in the complete Y incision group and in 4.2% (for both major and minor) in the curved incision group. The complete Y incision caused significantly more wound healing disorders compared to the remaining incision types (17.1% vs 3.1%, p = 0.007).CONCLUSIONSWound healing disorders are one of the major complications of revascularization surgery. Their incidence depends on the revascularization strategy and skin incision applied, with a complete Y incision giving the worst results.

Side-to-Side and End-to-Side Double Anastomosis Using the Parietal-Branch of the Superficial Temporal Artery-A Novel Technique for Extracranial to Intracranial Bypass Surgery: 3-Dimensional Operative Video.

In this 3-dimensional video, we perform a side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery (STA) to provide flow augmentation in a symptomatic 59-yr-old male with bilateral internal carotid artery occlusion at the origin, and left M1 segment occlusion. The patient suffered multiple left hemispheric strokes despite maximal medical therapy and was found to have poor hemodynamic reserve in the left hemisphere during evaluation with regional and global blood oxygenation level-dependent functional magnetic resonance imaging with CO2-challenge as well as quantitative magnetic resonance angiography and noninvasive optimal vessel analysis pre- and post-acetazolamide challenge. Postoperatively, the patient did very well and his hemodynamic studies improved significantly. The importance of this technique relies on the fact that we are using a single donor vessel to perform 2 anastomoses, and carries the following advantages: (1) the frontal STA branch remains intact and therefore can still be used at a later time if further revascularization is needed; (2) wound complications related to devascularizing the scalp from harvesting both STA branches are reduced; (3) 2 vascular territories are augmented (frontal and temporal) while using a single donor; (4) we are maximizing donor potential and optimizing cut flow index (CFI; total bypass flow postanastomosis divided by bypass cut flow) by flow augmenting 2 separate vascular beds therefore increasing demand. To explain that fourth point further: if the STA donor is able to carry a maximum 100 mL/min when cut, and after performing the first anastomosis bypass flow is only 37 mL/min, CFI will be 37/100=0.37, reflecting low demand, a poor indicator of graft patency, as previously published.1,2 By adding a second anastomosis which demands an additional 60 mL/min from the same STA donor, CFI (60+37)/100 improves to 1. Institutional Review Board approval was obtained for the review of patient chart and video files. Informed consent was obtained directly from the patient via telephone regarding use of media for educational and publication purposes.

Anatomy of the superficial temporal artery in patients with unilateral microtia

This retrospective study evaluated the anatomical distribution of the superficial temporal artery (STA) in supply of the temporoparietal fascial (TPF) flap for use in patients with unilateral microtia undergoing reconstruction. We aimed to determine whether embryologic arrest of pharyngeal arch development would lead to aberrant STA, which impedes reliable harvest of the TPF flap in patients requiring microtia repair. CT angiograms (CTAs) and 3D reconstruction of the face and neck of 41 patients with microtia, aged 6-21 years, were examined. The number of STA branches, branching pattern, vessel diameter, and the presence or absence of the external auditory canal atresia were documented. The STA crosses the zygoma on average 4mm more anterior to the porion (anterior-inferior lip of the tympanic part of the temporal bone) on the side with microtia compared to the nonmicrotia side. There were no statistically significant differences between vessel caliber or STA branches between the two sides. The STA is anatomically reliable for inclusion in TPF flaps, which is used for auricular reconstruction in patients with microtia. A TPF flap can be safely harvested by the routine technique; however, surgeons should be cognizant of the STA coursing more anteriorly on the microtia ear.

Improved visualization of superficial temporal artery using segmentedtime-of-flight MR angiography with venous suppression at 7T.

To evaluate the quality of time-of-flight MR angiography (TOF-MRA) with venous suppression at 7T on imaging superficial temporal artery (STA). A recently developed segmented TOF technique with reduced specific absorption rate (SAR) of venous suppression (VS) module was employed to achieve high-resolution arterial angiography without the contamination of venous signal. Images of segmented TOF with VS at 7T, TOF without VS at 7T, and TOF with VS at 3T were collected on 17 healthy volunteers. The number of STA branches and their local contrast achieved by the three methods were quantified and compared using paired t test. Segmented TOF with VS at 7T successfully suppressed venous signal without reducing the contrast of arterial angiography. The numbers of STA branches in 7T images were significantly higher than that in 3T images (5.79 vs. 4.50, p < 0.001). The contrast of 7T segmented TOF was significantly higher than 3T TOF (7.21 vs. 5.56, p = 0.006). Segmented TOF with VS at 7T displayed more branches of STA, while eliminating the signal of superficial temporal vein (STV). The improved visualization of STA will potentially facilitate the pre-operative assessment of STA in STA-MCA bypass surgery.

Iatrogenic Acute Intracranial Hematoma Following Drainage Catheter Removal: A Report of 2 Cases and Literature Review

This paper describes 2 unique cases of catheter removal-induced intracranial hemorrhage (CRIH). Acute intracranial hematoma including extradural, subdural, and ventricular hemorrhage is a rare but dangerous complication during catheter removal. Its occurrence is usually iatrogenic. The clinical data of two patients of CRIH were retrospectively collected with a brief review of the phenomenon. A huge subdural hematoma was confirmed in the first case and severe ventricular hematoma in the second case immediately after removing intracranial drains. Emergent craniotomy identified the parietal branch of superficial temporal artery and choroid plexus as the separate source of bleeding. According to the literature review, only 4 cases in 2 reports were diagnosed with CRIH. CRIH should be borne in mind during the procedure of removing a catheter for drainage. The chance of CRIH may be lowered by vigilant manipulation in the processes of both catheter insertion and removal. Early detection and timely evacuation is essential for good recovery. The first case is another example of CRIH in subdural cavity. However, CRIH in ventricles may also occur as demonstrated in the second patient, which was never reported to our knowledge.

Pedicled forehead flap for the reconstruction of maxillary defect: A novel surgical case report

“The tint of the forehead so exactly matches that of the face and nose that it must be the first choice” –Sir Harold Gillies and D. Ralph Millard Flaps from the frontal and temporal region have been used for mid-face, orbital, and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending on the requirement. Maxillectomy defects are usually covered with free flaps to fill the cavity. Here, we report an innovative technique in which a patient with a maxillectomy with external skin defect was covered with pedicled forehead flap based on the parietal and frontal branches of superficial temporal artery.

Acceleration of blood flow as an indicator of improved hemodynamics after indirect bypass surgery in Moyamoya disease

Objective: The ultrasonography findings in the superficial temporal artery (STA) in Moyamoya disease patients treated with indirect bypass remain unclear. We evaluated the time-related changes in ultrasonography findings of the STA main trunk and branches in patients with Moyamoya disease who underwent encephalo-duro-arterio-synangiosis (EDAS). Patients and methodsPatients (n=21, 30 sides) with Moyamoya disease who underwent EDAS at Fukuoka University Hospital were prospectively registered between 2008 and 2015. EDAS using the frontal and parietal branches of the STA was adopted in an indirect bypass procedure. Mean velocity (MV) and resistance index (RI) were used as ultrasonography markers, and their changes over time in the STA main trunk and branches were assessed. ResultsThere was a significant increase in MV in both the STA main trunk (p=0.001) and branches (frontal: p=0.005, parietal: p=0.003) at 3 months after EDAS, whereas there was a decrease in RI at 14days after EDAS (main trunk: p <0.001, frontal: p <0.001, parietal: p=0.014). In subgroup analysis of patients divided by EDAS outcome, compared with before EDAS, there were significant differences at 3 months after EDAS in MV (responders: main trunk: p=0.002, frontal: p=0.001, parietal: p=0.001; non-responders: main trunk: p=0.093, frontal: p=0.24, parietal: p=0.96) and RI (responders: main trunk: p<0.001, frontal: p<0.001, parietal: p=0.006; non-responders: main trunk: p=0.17, frontal: p=0.12, parietal: p=0.17). ConclusionsMeasurement of MV may be useful for predicting outcome at 3 months after EDAS.

Abstract: Composite Eye and Periorbital Allotransplantation Flap: A Cadaveric Study

INTRODUCTION: Composite tissue allotransplantation (CTA) has become a strong alternative in the last two decades in parallel with the developments in reconstructive surgery. Especially, reconstruction of the orbit and periorbital soft and bony tissue defects that occurs after traumatic avulsions, burn injuries, and cancer ablative operations is still challenging and it is almost impossible to obtain a satisfying result with conventional techniques. Although there are several allotransplantation models of various facial regions, a cadaver model of eyeball and periorbital tissues(EPT) is not described yet. The aim of this study is to describe a CTA model of eyeball and periorbital tissues on cadavers. 1,2 MATERIAL AND METHODS: The study was performed on 5 fresh human cadavers. The dissection was begun with anterior neck incision and external carotid artery was found. The facial artery and superficial temporal artery branches of external carotid artery were preserved. The pedicle of the skin island of the flap was included these arteries and external jugular vein. Later, a coronal incision was performed and frontal bone was exposed. Following a frontal osteotomy, the frontal lobe of the brain was reached. Frontal lobe was retracted exposing internal jugular vein and ophthalmic artery which is a branch of internal carotid artery. Ophthalmic, oculomotor and abducens nerves were also dissected and included in the flap. Finaly, a “box osteotomy” was performed to add the cavernous sinus in order to increase venous return from the orbit and the dissection was ended. RESULTS: The flap can be raised on the vascular pedicle of common carotid artery with jugular veins. An adequate venous return was observed in the flap after dye injection, and excellent perfusion was observed within CTA including eye. Laser-assisted indocyanine green angiography identified well-defined vascular network without presence of dye leakage. CONCLUSION: In this cadaver study, CTA model including EPT was described for the first time in the literature. The perfusion was confirmed which showed this transplantation is possible in the future. Although harvesting of this flap is difficult to perform, it constitutes a new alternative for reconstruction of periorbital region. We think that dual blood supply may reduce the ischemic process of the retinal ganglion cells. Additional measures should be taken to provide survival of RGC which results in optic nerve regeneration. We think that this model may be a cornerstone for future studies about eyeball transplantation. DISCLOSURE/FINANCIAL SUPPORT:The authors declare none disclosure. REFERENCES: 1. Dubernard JM, Devauchelle B. Face transplantation. Lancet. 2008 Aug 23;372(9639):603–4. 2. Borsuk DE, Christensen J, Dorafshar AH, Bojovic B, Sauerborn PJ, Christy MR, Rodriguez ED. Aesthetic microvascular periorbital subunit reconstruction: beyond primary repair. Plast Reconstr Surg. 2013 Feb;131(2):337–47.

Moyamoya Vessel Pathology Imaged by Ultra–High-Field Magnetic Resonance Imaging at 7.0 T

Prompt diagnosis of vessel pathology and appropriate treatment of moyamoya vasculopathy (MMV) are essential to improve long-term prognosis. The aims of our study were to explore the diagnostic value of ultra-high-field (UHF) magnetic resonance imaging at 7.0 T in MMV patients and to compare the applicability of two different 7.0 T vessel imaging modalities to 3.0 T magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). In a World Health Organization-registered and prospective imaging trial, patients were investigated at 7.0 T magnetization-prepared rapid-acquisition gradient echo (MPRAGE)-MRA and time-of-flight (TOF)-MRA, 3.0 T TOF-MRA, and by DSA. Six patients were included in our study and evaluated for MMV. 3.0 T TOF-MRA and 7.0 T MPRAGE-MRA were able to depict the complete major vascular tree and confirmed MMV-specific steno-occlusions of major intracranial arteries, as previously identified by DSA. 7.0 T TOF-MRA was limited to visualization of the circle of Willis as well as the internal carotid artery only. Donor vessels for bypass surgery (i.e., branches of superficial temporal artery) could be sufficiently visualized with all magnetic resonance modalities. Our results indicate that a specific 7.0 T vascular imaging protocol yields diagnostic information about vessel pathology in MMV that approximates conventional DSA. 7.0 T MPRAGE was superior to 7.0 T TOF-MRA due to shorter scanning times and better brain coverage. To date, however, limited availability of 7.0 T technology in medical facilities as well as technical and procedural constraints excludes a fair amount of patients from the clinical 7.0 T imaging process.

Anatomical variants of the superficial temporal artery in patients with microtia: a pilot descriptive study.

Superficial temporal artery (STA) based pedicled fascial flap plays a pivotal role in ear reconstruction for microtia patients. There is paucity of literature on the anatomy of the STA in microtia patients. The present study aimed to describe any possible anatomical variations seen in the STA of patients afflicted with microtia. Pre-operative carotid computer tomographic angiography images of patients under the microtia database of Plastic and Reconstructive Surgery Unit at a tertiary medical centre were selected and 3-dimensionally reconstructed. Measurements were made on the 3D reconstructed computed tomographic angiography images of the STA on both the sides of the microtic ear and the non-microtic ear to assess its various anatomical parameters. We managed to obtain a total of 39 computed tomographic angiography images of STAs for analysis. There was a significant difference in the number of main branches of STA between the two groups (P=0.006). The proportion of ears with 2 main branches was higher in the non-microtia group (89.5%) compared to the microtia group (45.0%). A significant difference was found in the STA diameter between the two groups (P=0.012). The mean diameter of STA in the non-microtia group was larger by 0.4 mm. Furthermore, the median angle of STA was larger on the side of the non-microtic ears compared to that of microtic ears by 24.5°, with a P-value of 0.011. The results of the study may be of clinical importance while planning and performing ear reconstructive surgeries using STA based pedicled fascial flaps.

A Novel Hypothesis of Visual Loss Secondary to Cosmetic Facial Filler Injection.

With the current tendency of increasing minimally invasive cosmetic surgeries, some rare but disastrous complications of facial filler injections come into sight, such as visual loss. The study aims to investigate the possible route that the injected droplet accesses the ophthalmic artery to explain and prevent such devastating complications. We searched the National Library of Medicine’s PubMed database for cases of visual loss secondary to cosmetic facial filler injection, and reviewed relevant case reports/surveys, as well as accompanying references. Data obtained were analyzed, with special interest in injected sites and filler material, and clinical features of visual loss. Based on the anatomy of facial vessels, we inferred the possible route of injected droplet migrating from injection sites to ophthalmic artery. Most physicians propose a retrograde embolic mechanism, but the culprit artery when injecting different sites is not determined. We consider accidentally breaking into supraorbital artery or supratrochlear artery may cause occlusion of ophthalmic artery when injecting into glabella or forehead region. Speaking of the nasolabial fold and nasal dorsum region, any injections in the anastomosis of the dorsal nasal artery, angular artery, and lateral nasal artery can lead to retrograde embolism. Similarly, in the temporal region, we believe there is abnormal anastomosis between frontal branch of superficial temporal artery from external carotid artery and supraorbital artery from ophthalmic artery. In our hypothesis, we can explain the accompanying brain infarction after iatrogenic visual loss. If the injecting pressure is forceful enough, it may push the embolic materials into middle cerebral artery. Although iatrogenic ophthalmic artery occlusion is a rare complication after the facial filler injection surgery, it is usually devastating. Both the patient and the surgeon should be aware of the risk of irreversible blindness. Ideally, the injection sites should avoid the small vessels nearby, the injecting force and velocity should be as gentle and slow as possible.

Reconstruction of full-thickness lower eyelid defect using superficial temporal artery island flap combined with auricular cartilage graft.

Full-thickness lower eyelid defect is one of common surgical diseases, which may lead to exposure keratopathy, corneal ulceration, and blindness. The aim of this study was to investigate the effect of superficial temporal artery island flap combined with auricular cartilage graft on the repair of full-thickness lower eyelid defect.In this study, the reconstructions in 6 patients who had unilateral full-thickness lower eyelid defects due to ocular traumas or surgical resections of malignant tumors were carried out. The island flap of the frontal branch of superficial temporal artery reconstructed the outer layer and the total lower lid was supported with the plane of an auricular cartilage strip, offering a proper contour and physical strength to maintain a normal eyelid height. The follow-up time ranged from 6 to 24 months. No major complications including partial or total flap necrosis, signs of infection, venous congestion, and hematoma were seen in any of the patients, and all cases have been reconstructed well both aesthetically and functionally, showing esthetic eyelid contour, good color, and texture match.Superficial temporal artery island flap combined with auricular cartilage graft is a useful method functionally and cosmetically for the reconstructions of full-thickness lower eyelid defects because of its advantages including rich vascularity based on superficial temporal artery, wide pedicle rotational arc, which could be transferred throughout the face region, good eyelid contour with color and texture match, limited donor-site scar, and minimal postoperative morbidity.

Application of the parietal branches of superficial temporal artery island flap in complex scalp defects

Objective To investigate the application of the parietal branches of superficial temporal artery island flap in the complex scalp defects.Methods A parietal branches of superficial temporal artery island flap on the ectatic scalp flap was designed to repair the complex scalp defects in 25cases and the repairing effect was observed.Results The island flaps were survived completely in 24patients,in which 1 patient had partial necrosis because of the flap tension was too large,but healed after local dressing and debridement.After followed up 6～ 12 months,the color and texture of the flap were the same to the surrounding normal scalp,and the shape was satisfactory.The flap donor site of hair growth was good,with well healing and no obvious complications.Conclusions The parietal branches of superficial temporal artery island flap can repair the complex scalp defects with the flexible flap design and movement.The flap survives well and the repair area is large.The flap and the surrounding scalp connects good.Therefore,it is a good method strongly recommended for small area complex scalp defects repair in clinics. Key words: Scalp defects; Parietal branches of superficial temporal artery; Island flap

Zygomatico-Orbital Artery as a Recipient Vessel for Microsurgical Head and Neck Reconstruction

The selection of recipient vessels in head and neck reconstruction is one of the key factors influencing its difficulty and outcome. We report a case of a microsurgical scalp reconstruction using the zygomatico-orbital artery as a recipient vessel.A 71-year-old woman had intractable skin ulcers on her head after neurosurgeries. Computed tomography angiography findings showed that the superficial temporal artery was obstructed and that the zygomatico-orbital artery ran forward and upward. She underwent scalp reconstruction using a free anterior lateral thigh flap. The zygomatico-orbital artery was dissected distally, cut, and turned over cranially. The diameter of the zygomatico-orbital artery was 1.2 mm. The blood flow through the zygomatico-orbital artery was sufficient. The thinned scalp area was excised, and some of the titanium devices and infectious tissues were removed. An anterior lateral thigh flap measuring 20 × 9 cm was harvested and transferred to the defect in the head. The discrepancy in calibers was within double, and the zygomatico-orbital artery fit the descending branch of the lateral circumflex femoral artery. The flap was transferred successfully.The zygomatico-orbital artery is one of the branches from the external carotid artery and supports the suprazygomatic territory. The zygomatico-orbital artery is present in 78% to 92% of people and originates from the superficial temporal artery and sometimes from the frontal branch of superficial temporal artery. The mean diameter of the zygomatico-orbital artery at origin is reported to be 1.20 mm. The zygomatico-orbital artery is another option as a recipient vessel in head and neck reconstruction.

Double-Skin Paddled Superficial Temporofascial Flap for the Reconstruction of Full-Thickness Cheek Defect

The most common causes of cheek defects include trauma, burn, and tumor resections. In the reconstruction of the defects in this region, it is essential to use similar or adjacent tissue considering the aesthetic and functional properties. For this purpose, numerous local, regional, or distant free flaps were described. The local flaps harvested from the head and neck region are the most frequent methods because of the similar skin color, texture, and compatibility with cheek.In this study, the reconstruction in a 29-year-old male patient who had a full-thickness cheek defect due to tumor resection on the left side was performed, wherein a hairless skin island was carried through the frontal branch of superficial temporal artery for oral mucosa, and a hairy skin island through the parietal branch of the same pedicle was carried for the bearded skin defect. No complication occurred postoperatively and both aesthetic and functional satisfactory results were obtained, providing the oral mucosal and natural beard integrity. Donor-site scarring and temporal alopecia were recorded as the disadvantages of this method.This technique is a useful method for the reconstruction of full-thickness cheek defects because of its advantages including compatibility of color and texture, reliable blood supply, requiring single-session procedure, and being able to carry 2 different skin islands on the same pedicle.

Florid Arteritis Confined to a Single Branch of the Superficial Temporal Artery

for the integrity of the data and the accuracy of the data analysis. Financial Disclosure: None reported. Funding/Support: This work was supported by Eye Tu- mor Research Foundation, Philadelphia, Pennsylvania (Drs J. A. Shields and C. L. Shields). Role of the Sponsor: The sponsor had no role in the de- sign and conduct of the study; in the collection, analy- sis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. 1. Zimmerman LE, Garron LK. Melanocytoma of the optic disc. Int Ophthalmol Clin. 1962;2:431-440. 2. Apple DJ, Craythorn JM, Reidy JJ, Steinmetz RL, Brady SE, Bohart WA. Ma- lignant transformation of an optic nerve melanocytoma. Can J Ophthalmol. 3. Shields JA, Shields CL, Eagle RC Jr, Lieb WE, Stern S. Malignant melanoma associated with melanocytoma of the optic disc. Ophthalmology. 1990;97 4. Meyer D, Ge J, Blinder KJ, Sinard J, Xu S. Malignant transformation of an op- tic disk melanocytoma. Am J Ophthalmol. 1999;127(6):710-714. 5. Shields JA, Demirci H, Mashayekhi A, Shields CL. Melanocytoma of optic disc in 115 cases: the 2004 Samuel Johnson Memorial Lecture, part 1. Ophthalmology. 6. Shields JA, Demirci H, Mashayekhi A, Eagle RC Jr, Shields CL. Melanocy- toma of the optic disk: a review. Surv Ophthalmol. 2006;51(2):93-104. 7. Horgan N, Shields CL, Swanson L, et al. Altered chromosome expression of uveal melanoma in the setting of melanocytosis. Acta Ophthalmol. 2009;87 branches of the superficial temporal artery. In fact, sur- geons usually fail to specify which branch was biopsied when they submit specimens, and no histological data exist regarding which branch is more likely to demon- strate arteritis. Recently, it was suggested that the parietal branch, rather than the frontal branch, should be biopsied in pa- tients with suspected temporal arteritis. 3 This approach eliminates the remote risk of facial nerve injury and usu- ally hides the scar behind the hairline. However, this rec- ommendation was predicated on the assumption that the prevalence of arteritis is equal in the parietal and frontal branches. We now show that selective involvement of a single vessel branch can occur in temporal arteritis. Magnetic resonance imaging has been used to com- pare the involvement of the parietal vs frontal branch in temporal arteritis. In 21 patients with suspected giant cell arteritis, involvement was rated by noting the amount of mural thickening and gadolinium enhancement of the vessel and perivascular tissue. 4 On the left side, abnor- malities were present in 14 patients in the frontal branch and in 6 patients in the parietal branch. On the right side, A Florid Arteritis Confined to a Single Branch of the Superficial Temporal Artery B iopsy of the superficial temporal artery provides vital confirmation of the diagnosis of giant cell arteritis. The vessel splits into 2 main branches: frontal and parietal. It is unknown which branch is most likely to yield a positive biopsy finding or, indeed, whether arteritis is ever confined to a single branch. Report of a Case. A 69-year-old woman had a 5-week history of neck stiffness and malaise. The erythrocyte sedi- mentation rate was 55 mm/h. A 30-mm segment of the parietal branch of the left superficial temporal artery was harvested. It was processed with hematoxylin-eosin stain and an elastic Van Gieson stain. A total of 108 sections were examined at 36 different levels. None showed evi- dence of arteritis ( Figure 1 ). Two days later, a 30-mm section of the frontal branch of the left superficial tem- poral artery was biopsied. Every section showed exten- sive granulomatous inflammation ( Figure 2 ). The pa- tient was treated with prednisone and her symptoms resolved. Comment. It is crucial to obtain a biopsy specimen of adequate length to avoid the problem of “skip areas” in the superficial temporal artery. It is also important to ex- amine the specimen thoroughly by reviewing sections cut at many levels because inflammation can be confined to just a few portions of the artery. Otherwise, there is risk of a false-negative biopsy result. 1,2 We describe an ex- treme example of a skip area: a parietal branch com- pletely free of inflammation in a patient with extensive arteritis of the frontal branch. To our knowledge, no prior report has compared pathological findings in the 2 B Figure 1. Patient showing biopsy sites from the parietal and frontal branches of the left superficial temporal artery (A), and representative sections, spaced evenly from 9 different levels of the parietal branch of the left superficial temporal artery, showing no evidence of arteritis (hematoxylin-eosin, original magnification ⫻12) (B). ARCH OPHTHALMOL / VOL 130 (NO. 10), OCT 2012 WWW.ARCHOPHTHALMOL.COM ©2012 American Medical Association. All rights reserved. Downloaded From: http://archopht.jamanetwork.com/ by a UCSF LIBRARY User on 08/10/2015

Extracranial-Intracranial Bypass Surgery for Stroke Prevention in Hemodynamic Cerebral Ischemia

Context Patients with symptomatic atherosclerotic internal carotid artery occlusion (AICAO) and hemodynamic cerebral ischemia are at high risk for subsequent stroke when treated medically. Objective To test the hypothesis that extracranial-intracranial (EC-IC) bypass surgery, added to best medical therapy, reduces subsequent ipsilateral ischemic stroke in patients with recently symptomatic AICAO and hemodynamic cerebral ischemia. Design Parallel-group, randomized, open-label, blinded-adjudication clinical treatment trial conducted from 2002 to 2010. Setting Forty-nine clinical centers and 18 positron emission tomography (PET) centers in the United States and Canada. The majority were academic medical centers. Participants Patients with arteriographically confirmed AICAO causing hemispheric symptoms within 120 days and hemodynamic cerebral ischemia identified by ipsilateral increased oxygen extraction fraction measured by PET. Of 195 patients who were randomized, 97 were randomized to receive surgery and 98 to no surgery. Follow-up for the primary end point until occurrence, 2 years, or termination of trial was 99% complete. No participant withdrew because of adverse events. Interventions Anastomosis of superficial temporal artery branch to a middle cerebral artery cortical branch for the surgical group. Antithrombotic therapy and risk factor intervention were recommended for all participants. Main Outcome Measure For all participants who were assigned to surgery and received surgery, the combination of (1) all stroke and death from surgery through 30 days after surgery and (2) ipsilateral ischemic stroke within 2 years of randomization. For the nonsurgical group and participants assigned to surgery who did not receive surgery, the combination of (1) all stroke and death from randomization to randomization plus 30 days and (2) ipsilateral ischemic stroke within 2 years of randomization. Results The trial was terminated early for futility. Two-year rates for the primary end point were 21.0% (95% CI, 12.8% to 29.2%; 20 events) for the surgical group and 22.7% (95% CI, 13.9% to 31.6%; 20 events) for the nonsurgical group (P = .78, Z test), a difference of 1.7% (95% CI, −10.4% to 13.8%). Thirty-day rates for ipsilateral ischemic stroke were 14.4% (14/97) in the surgical group and 2.0% (2/98) in the nonsurgical group, a difference of 12.4% (95% CI, 4.9% to 19.9%). Conclusion Among participants with recently symptomatic AICAO and hemodynamic cerebral ischemia, EC-IC bypass surgery plus medical therapy compared with medical therapy alone did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years. Trial Registration clinicaltrials.gov Identifier: NCT00029146