Superficial Temporal Vessels Research Articles

The reverse superficial temporal artery flap from the preauricular region, for the small facial defects

For the reconstruction of facial defects, the retroauricular flap is generally used. However, this flap has disadvantages, such as venous return disturbance and reddish skin colour peculiar to the retroauricular region. Here, we report the reverse superficial temporal artery (STA) flap, elevated from the preauricular region. In our method, the flap is retrogradely elevated including the STA under the skin island in the preauricular region and the temporoparietal fascia around the superficial temporal vessels in the temporal region. The donor site is closed primarily or by the retroauricular flap. Five cases with a pedicled flap and one case with a free flap were treated using our method. In one case, a minor congestion of the flap occurred postoperatively, and temporary facial nerve palsy in another case. In all cases, the results were cosmetically good, and the scar at the donor site was inconspicuous. As compared to the retroauricular flap, our method is easier to perform and the flap has a reliable blood circulation. Moreover, it can be used with both a pedicled and a free flap, leaving an inconspicuous scar at the donor site, and a colour match without reddish skin. Therefore, when considering reconstruction of small-sized defects on the face, our method is more useful than the retroauricular flap.

P-012 A mathematical model of vascular tortuosity using optimality analysis

Introduction/PurposeAlthough vascular tortuosity is a ubiquitous phenomenon, no mathematical models exist to describe its shape. Given that the shape of tortuous vessel curves seems fairly uniform across great variations in...

Pre-auricular and ascending helical free composite flap in reconstructing an alar defect resulting from a human bite: a case report

Full-thickness defects of the nose result in severe aesthetic and functional problems. Nasal alar defects are frequently caused by trauma, surgical resection or congenital deformities, yet an alar defect due to a human bite is quite rarely seen. For a successful alar reconstruction, selected tissue must be similar to nasal structures in texture, color and thickness. The structural similarities between the nasal alae and auricular helices have allowed the use of free helical composite flaps for the repair of nasal defects. In this article, we report a 36-year-old male patient who had a right alar defect caused by a human bite. The defect was successfully reconstructed with a reverse flow superficial temporal vessel based pre-auricular and ascending helical free composite flap. Since the color and the texture of the flap was compatible with the nose integuments, this flap enjoyed of an optimal integration in the central facial area.

Scalp Reconstruction with Inverted Myocutaneous Latissimus Free Flap and Unmeshed Skin Graft

Limited skin paddle size, peripheral thinning, or lack of cerebral expansion after radiotherapy may necessitate secondary sculpting after latissimus free flap reconstruction of large scalp defects. This series presents a novel modification of the myocutaneous latissimus dorsi free flap for use in large scalp defects. After superficial artery isolation, titanium mesh is placed into the calvarial defect to recapitulate the inner table. The myocutaneous latissimus flap is harvested in standard fashion, deepithelialized, and inverted. The skin paddle is placed over titanium mesh to fill the calvarial defect, then sewn over a drain. The inverted latissimus muscle is draped over the defect and extended peripherally beneath the pericranium. The flap is sewn to the scalp internally using a vest-over-pants suture pattern, and the thoracodorsal and superficial temporal vessels are anastomosed and left facing outward. Unmeshed skin graft is draped over the muscle and vessels then sutured loosely. Patients with complex scalp defects whose soft tissue defect exceeded the size of latissimus skin paddle available with primary closure were considered eligible for inverted latissimus free flap reconstruction. Follow-up range was 6 months to 12 months. Over a 2-year period, five patients underwent inverted latissimus free flap reconstruction. Scalp defects ranged in size from 10 × 8 cm to 17 × 11 cm. The calvarial defect was smaller than the soft tissue defect in all cases. All flap donor sites were closed primarily. All five flaps took, and donor site outcomes were acceptable. Aesthetic outcomes were satisfactory with well-contoured, calvarial-shaped results. Cosmesis was most notably limited by skin graft joint lines. No patients underwent secondary surgical revision. The inverted myocutaneous latissimus free flap is a safe and effective method for reconstructing large or irradiated scalp defects.

Reconstruction of the Cheek after Large Port-Wine Stain Lesion Resection

A laser is commonly used in treatment of port-wine stain (PWS). Although observable lightening of the stains can be achieved, complete removal is rare. A significant proportion of lesions are resistant to laser treatment, including hypertrophic lesions and scars developed after improper (unsuccessful) treatments. Alternatively, resection is used to eliminate such lesions, but the reconstruction of the aesthetic appearance of the cheek after large lesion resection remains a huge challenge. Ten patients with a PWS larger than two-thirds of the cheek were selected for this study. In those patients, prefabricated induced expanded flaps carried by the superficial temporal vessels were prepared to cover the defect areas after resection of the PWS lesion. In eight patients, all the donor sites and defect areas were covered primarily with the expanded flaps, which then survived completely. All patients were satisfied with the cheek appearance after reconstruction with prefabricated induced expanded flaps, which provided a good match for color and texture, restored facial contour, placed scars in a concealed location, and achieved minimal donor-site morbidity. Two of the ten patients did not finish the original surgical plan due to infection or damage to the vascular pedicle. We show that the technique of using prefabricated expanded flaps based on the superficial temporal vessels can be an effective option for repairing large cheek defects after PWS resection.

Flaps pedicled on the superficial temporal artery and vein in facial reconstruction: A versatile option with a venous pitfall

Flaps pedicled on the superficial temporal vessels are versatile in reconstruction of the face and scalp. Various tissues can be harvested and flexible pivot points and long pedicles allow for them to reach the entire face. Colour and texture match is good, and morbidity at the donor site is usually minimal. However, venous anatomy of the temporal area is unpredictable, and this anatomical point has not been clearly reported in papers and anatomical atlases. One must be aware of the risk of venous inconsistency and plan the pedicle accordingly. In the absence of a suitable vein, drainage can be provided through concomitant veins in a sufficient cuff of fascia around the pedicle's artery. We have reviewed published reports about reconstructive possibilities provided by temporal flaps, for descriptions of the venous drainage of the temporal area, and for salvage procedures in case of venous stasis. We present our own salvage procedure, the “modified poor man's leech”, in which continuous venous oozing from a de-epithelialised area is maintained by topical heparin and low molecular weight heparin injections and may save a congested flap.

Application of bi-pedicled frontal expanded flap for cervical cicatricial contracture

To investigate the therapeutic effect of bi-pedicled frontal expanded flap for cervical cicatricial contracture. Tissue expanders were implanted under frontal muscle. After expansion, the frontal flaps were designed based on bilateral superficial temporal vessels and were transferred to the neck wound. The cervical spine movement and the mento-cervical angle was measured and analyzed by SPSS16.0 and t test. From September 2006 to May 2010, 7 patients were treated by this method. The range of active cervical movement was improved in all direction. The mento-cervical angle decreased from (152.7 +/- 1.9) to (90.7 +/- 2.2) degrees after operation. The patients were followed up for 5 months to 3 years with satisfactory result and no contracture recurrence. The bi-pedicled expanded frontal flap has a reliable blood supply and is very suitable for cervical cicatricial contracture with good functional and esthetic results, leaving less morbidity at donor site.

Repair of cervicofacial scar by forehead expansive skin flap double-pedicled with superficial temporal vessels

To explore the clinical efficacy of using forehead expansive skin flap double-pedicled with superficial temporal vessels for repairing male cervicofacial scar. From July 2005 to June 2009, 13 male patients with an average age of 27 years old (range: 21 - 38) were operated by the above method. The scar-repairing area was from 14 cm × 5 cm to 32 cm × 15 cm. The procedure was carried out in three stages. Firstly, ultrasound Doppler was used to detect and mark the location and orientation of superficial temporal artery. A proper cavity was created under the forehead muscle and then the appropriate expander embedded through the scalp incision. The expander was expanded first by injecting normal saline at 1 or 2 weeks post-operation. After that, the injection was repeated by 3 or 5 days. The volume ratio of injection to expander was (1.5-3.5):1. Secondly the forehead expansive skin flap was designed with proper hair follicle scalp pedicled by bilateral superficial temporal artery when the expansion was completed. After removal of the expander, the rectangle expansive skin flap with hair follicle scalp was transferred through the double pedicle. The cervicofacial scar was excised according to the size of the transferred expansive skin flap (25 cm × 6 cm to 32 cm × 9 cm). And the flap was adjusted with hair follicle scalp to the middle of the chin area in order to obtain the normal beard appearance. Donor site were closed directly. Thirdly, the pedicle skin flap were cut and restored after one month. The volume expanded for each expander ranged from 420 to 800 ml (mean: 660). The average expansion time was 4 months (range: 3 - 5). All flaps survived well. Donor site were closed directly. Both chin and beard looked normal. Repairing hypertrophic scar and reconstructing beard in cervicofacial area with forehead expansive skin flap pedicled by bilateral superficial temporal artery is a valuable and safe method. The donor site is scarless. And the reconstructed chin and beard are normal both functionally and aesthetically.

30-Year Follow-Up of the First Successfully Replanted Ear

30-Year Follow-Up of the First Successfully Replanted Ear

Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular Condyle Fracture of the Mandible

This article reports a modified preauricular approach for intracapsular condyle fracture (ICF) of the mandible and evaluates the stability of various internal fixation methods in the temporomandibular joint (TMJ) division of the Shanghai Ninth People's Hospital. One hundred fifty-one patients with 208 ICFs diagnosed by panoramic radiograph and computed tomographic (CT) scan received open treatment in the TMJ division from 1999 to 2008. Their charts were reviewed. Classification of the fracture was based on coronal CT scan. Forty-three patients also underwent magnetic resonance imaging before the operation to check displacement of the disc. A modified preauricular approach was used for all patients. Various internal fixation methods from wire, to screw, to plate were evaluated for stability. There were 110 ICFs of type A fracture, 60 of type B fracture, 9 of type C fracture, 25 of type M fracture, and 4 fractures without displacement. A modified preauricular approach was used for open treatment, which can better expose and protect the TMJ and superficial temporal vessels. Wire and plate is the commonly used stable fixation method for type A, B, and M fractures, which accounted for 56.7% (101/178). Small fracture fragments were removed with disc repositioning for all type C fractures (n = 9) and some type B (n = 9) and M fractures (n = 5). Three type M fracture and 3 nondisplaced ICFs were treated closed. Eighty-nine patients with 115 ICFs had postoperative CT scan, which showed anatomic and nearly anatomic fracture reduction rates of 95.6%. Thirty-five patients with 44 ICFs had long-term follow-ups from 3 months to 5 years. Among them, 63.2% (n = 12/19) pediatric ICFs had continuous condyle growth after open reduction and rigid fixation; 92% adults had ICFs that healed well (n = 23/25). Postoperative complications were facial nerve injury (n = 3), TMJ clicking (n = 1), and condyle resorption that required plate removal (n = 4). A modified preauricular approach provides better exposure and protection of the TMJ and superficial temporal vessels. Wire and plate provides stable fixation for type A and some type B and M fractures. Open reduction and rigid fixation produce good results for adult patients.

Facial Transplantation: An Anatomic and Surgical Analysis of the Periorbital Functional Unit

Complete loss of eyelid pair is associated with chronic discomfort, corneal ulceration, and visual impairment. Contemporary reconstructive techniques rarely provide functionally acceptable results. Composite tissue allotransplantation may provide a viable alternative. This study reports on neurovascular anatomy and technical details of harvesting an isolated periorbital unit and discusses its functional potential. Twenty-four hemifaces (12 fresh cadavers) were dissected to study surgically relevant neurovascular structures and to develop an efficient harvest method. Angiographic analysis was performed in seven hemifaces following harvest. The superficial temporal and facial vessels demonstrated consistent location and diameters. Anatomic variability was characterized by the absence of the frontal branch of the superficial temporal artery or facial-to-angular artery continuation, but never of both vessels in the same hemiface. Angiographic analysis demonstrated filling of the eyelid arcades, provided the anastomoses between the internal and external carotid branches were preserved. The facial nerve exhibited consistent planar arrangement and diameters in the intraparotid and proximal extraparotid regions, but less so in the distal nerve course. The inferior zygomatic and buccal branches frequently coinnervated the orbicularis oculi and lower facial muscles with an unpredictable intermuscular course. Based on the foregoing, an effective surgical harvest of the periorbital composite was developed. Surgical harvest of a functional periorbital allotransplant is technically feasible. Revascularization of the isolated periorbital unit is influenced by variations in regional anatomy and cannot be guaranteed by a single vascular pedicle. The orbicularis oculi muscle and its innervation can be preserved, and recovery, albeit without the certainty of reflexive blinking, is expected.

Use of Wide Bipedicled Pericranial Flap in Anterior Scalp Reconstruction

Pericranial flap is a composite flap involving the periosteum of the skull with its overlying loose areolar tissue termed subgaleal fascia. The multiple blood supply of the pericranial tissue enables this versatility, with a rich, anastomosing arterial supply from the supraorbital, supratrochlear, superficial temporal, posterior auricular, and occipital vessels. Thus, the shape, size, and location of the pericranial flap could be altered as long as a sufficient pedicle width could be fashioned to maintain a blood supply. In our study, we have performed wide bipedicled pericranial flap in scalp reconstruction in 2 cases. After tumor excision was completed, a pericranial flap was planned on the caudal side of the defect. A bipedicle-based pericranial flap was outlined with the use of a sharp dissection; this flap was elevated in a submusculoaponeurotic plane. The bipedicled pericranial flap, whose arterial supply was from the superficial and posterior auricular arteries, was transposed to the frontal defect.We preferred a bipedicled flap, whose arterial supply is from the superficial temporal and posterior auricular arteries to augment vascular supply. If a large, long pericranial flap is required, making the flap pedicled ensures stable blood supply.

The Temporoparietal Fascial Flap for Endoscopic Cranial Base Reconstruction: Technique, Indications, and Case Series

Objective: To describe our indications for the temporoparietal fascia flap (TPFF) in endoscopic cranial base reconstruction, our evolution in technique, and our case series. Methods: Retrospective chart review at a tertiary care center. Results: The two patients in our series had malignant neoplasms of the skull base that received preoperative radiation. The intranasal vascularized options for cerebrospinal fluid (CSF) leak repair were therefore unavailable. One patient was treated for osteoradionecrosis of the central cranial base, and the other patient received a TPFF for reconstruction after primary resection. The TPFF flap was harvested in the standard open fashion based on the superficial temporal vessels. It was then passed through the infratemporal fossa into the defect of the skull base and nasopharynx, without the need for osteotomies, and secured into place. Median follow-up of 14 months demonstrated no CSF leak. One patient developed severe epistaxis related to the resection requiring embolization. There was no donor site morbidity. Currently, both patients have fully healed. Conclusion: The TPFF is an effective means of endoscopic cranial base reconstruction with minimal complications. It serves as a reliable vascularized method of reconstruction when other intranasal vascularized flaps are unavailable.

Firm elevation of the reconstructed auricle with a retroauricular fascial flap wrapping an EH (a mixture of epoxide acrylate malelic and hydroxyapatite) composite wedge

Nagata's two-stage methods for ear reconstruction of congenital microtia have been widely used. In this study, we present another option to the second stage in Nagata's method. After the implanted auricle was separated from the bed, instead of using a temporoparietal fascial flap to wrap a cartilage wedge, we developed a new alternative using the retroauricular fascial flap wrapping an EH (a mixture of epoxide acrylate malelic and hydroxyapatite) composite wedge. In addition, it is quite often that, from a frontal view in the Chinese population, the upper and lower parts of the auricle are more prominent than the middle part. We designed an EH composite wedge with a special shape to obtain a firm elevation. Between July 2005 and June 2007, 117 patients underwent this operation; and the follow-up period ranged from 6 to 24 months, postoperatively. Among the 117 cases, the wedge was exposed only in one patient and hypertrophic scars were detected in two cases. Among the rest of the patients, there were no complications such as breakdown, exposure or infection. All the patients had satisfactory ear projection. This technique has the advantages of being straightforward and time saving. It is possible to create a firm elevation and to preserve the temporoparietal fascial flap and superficial temporal vessels for possible use in case of traumatic or secondary ear reconstruction in the future. Meanwhile, we clearly demonstrated that the EH composite wedge is a suitable material in the second stage of the reconstruction of the auricle.

PR10 HELIX SWITCH FOR RECONSTRUCTION OF SEGMENTAL HELICAL RIM/SCAPHA DEFECT: A CASE REPORT

A 35 year old man presented to clinic having lost the central two thirds of his left helix and lateral scapha following a human bite. A switch procedure using the root of the opposite helix and adjacent scaphoid cartilage was considered and performed secondarily.The right helix was harvested with a long pedicle length on the superficial temporal (ST) vessels. The vascular pedicle emerged posteriorly from the graft at its transferred site and was tunnelled under the ear to the preauricular ST vessels for anastomosis. Primary donor site defect was closed with a postauricular flap. Postoperatively leech therapy was commenced on day one for a total duration of 4 days. The patient was discharged and followed up in clinic with no complications.Ear reconstruction remains one of the most challenging aspects of reconstructive surgery. Here, we report of a novel alternative ear switch procedure for reconstruction of the helical rim.

Superficial Temporal Recipient Vessels in Microvascular Orbit and Scalp Reconstruction of Oncologic Defects

The superficial temporal artery and vein (STA/V) are often considered suboptimal recipient vessels due to anecdotal reports that they are unreliable and prone to spasm. This is unfortunate, as their position greatly facilitates reconstruction of the scalp and orbit. We present our experience with 28 patients who underwent microvascular craniofacial reconstruction of oncological defects using the STA/V as recipients over a 4-year period at a single institution. Rates of vessel thrombosis, total flap loss, and partial flap loss were not significantly different from 282 flaps anastomosed to neck vessels. With knowledge of the anatomy and proper technique, the STA/V are reliable and available in most patients and can facilitate microvascular orbit and scalp reconstruction. The proximity they offer allows more flexibility in flap pedicle length requirement and avoids the use of vein grafts. Caution should be exercised if there is a history of radiation therapy.

Superficial Temporal Vessels as a Reserve Recipient Site for Microvascular Head and Neck Reconstruction in Vessel-Depleted Neck

Reconstructions for local recurrence and second primary oromucosal cancer remain a challenge because the recipient vessels are depleted in the neck. The objective of this study was to investigate the outcome of superficial temporal vessels, as reserve recipient vessels for microvascular surgery in vessel-depleted neck patients. Between March 2003 and August 2005, the superficial temporal vessels were used as a recipient site for microsurgical head and neck reconstruction in 15 patients with vessel-depleted necks. There was no flap loss in any of the reconstructions. One venous anastomosis was revised for thrombosis and flap salvaged. The superficial temporal vessels provide a good alternative for head and neck reconstruction in vessel-depleted neck patients with the advantages of radiation spared, constant anastomy, and suitable size. It obviates the need for long pedicle flaps or the use of vein grafts. Care must be taken not to damage or kink the vein.

Lateral Circumflex Femoral Artery: Not Always Atherosclerosis-Resistant

Sir: We read with great interest the article by Halvorson, Taylor, and Orgill (Plast. Reconst. Surg. 121: 121, 2008) about the radiographic patency of the descending branch of the lateral circumflex femoral artery. The group noted radiographic mean stenosis rates of 10 percent in the descending branch of the lateral circumflex femoral artery and 12.5 percent in the profunda femoris artery, suggesting that the vascular territory supplied by the profunda femoris is largely “atherosclerosis-resistant.” We are submitting a cautionary statement that in the end-stage renal disease patient these findings may not hold true. We recently reconstructed a 13 × 9-cm full-thickness defect of the anterior scalp created after excision of a malignant fibrous histiocytoma. The patient, a 75-year-old man with hypertension and coronary artery disease, underwent a renal transplant 12 years ago. Preoperatively, there was no overt evidence of significant lower extremity vascular disease, as he was noted to have palpable pulses distally. Two lateral thigh perforating vessels were identified on Doppler ultrasonography. We performed an anterolateral thigh flap reconstruction based on a single intramuscular perforator from the lateral circumflex femoral artery to the superficial temporal vessels. Although the flap perforator itself was relatively soft, the entirety of the lateral circumflex femoral artery was extensively and completely calcified. The extensive calcification resulted in a challenging anastomosis, possible only by using a slightly larger needle/suture (8-0) taking bites from the inside aspect of the flap vessels, as coming through the calcified vessel wall from the adventitial side proved impossible. The recipient vessels were soft and had good inflow without evidence of calcification. Postoperatively, the patient did well and the flap survived in its entirety. Pathologic calcification of the vascular system in dialysis patients and transplant recipients has been recognized since the 1960s. In 1973, Tatler and Baillod2 examined plain radiographs and described calcium deposition in a “ring” or “tubular” pattern in 27 percent of patients starting dialysis, with this proportion doubling over a 3- to 4-year period. Using more sophisticated imaging, such as electron beam technology, a 60 to 90 percent prevalence in dialysis patients is noted, with the most consistently associated factors being advanced age and number of years on dialysis.3 The cause of arterial calcification is unclear but may be related to dialysis calcium concentration and the pathologic process of renal osteodystrophy. In dialysis patients, angiographic studies note that arterial calcifications are not necessarily associated with stenotic coronary artery lesions. Although some intimal calcification is present in dialysis patients, the pipe and tubular patterns described by Tatler and Baillod and others are more consistent with calcium deposition in the tunica media. These observations have led to an alternative arterial abnormality occurring in chronic kidney disease, a process called chronic kidney disease–associated arteriopathy.4 Although not causing arterial occlusion, as would be visualized on angiography, medial calcification in these patients leads to extensive arterial thickening and stiffening, making microanastomosis of these vessels extremely difficult. Although Halvorson et al. provide radiographic support for the relative atherosclerosis-sparing of the profunda femoris system, the findings were not correlated with the clinical appearance of the vessels because their patients never went on to surgery. For the surgeon planning any microsurgical reconstruction in patients with a history of end-stage renal disease, we have learned that the lateral circumflex femoral artery system may not be spared from disease. Mehul R. Kamdar, M.D. Christine Rohde, M.D. Jason A. Spector, M.D. Division of Plastic Surgery New York Presbyterian Hospital Columbia University College of Physicians and Surgeons New York, N.Y.

Repairing of defect around orbit with a forehead flap

Objective To study the method of repairing the periorbit tissue defect using a forehead myocutaneous flap transplantation. Methods The retrospective investigation was performed in 6 cases of the periorbit tissue defect being repaired with the forehead flap with a pedicle of superficial temporal ves-sels and fascia during 2001 to 2007 by mierosurgieal techniques. The size of transplantatcd skin flap ranged from 2.5 cm×3.0 cm to 8 cm×5 cm. Results Six cases of forehead flap transplantation with a superficial temporal vessels and fascia pedicle were completely survival and achieved aesthetic contouring. Conclusion The method of forehead flap transplantation with a superficial temporal vessels and fascia pedicle is a safe and potent choice for the reconstruction of the periorbit tissue defect. Key words: Flap; Forehead flap; Repair; Tumor; The defect

Pedicled Temporoparietal Galeal Flap for Reconstruction of Intraoral Defects

In this report we aim to describe the surgical technique required to utilize the pedicled temporoparietal galeal flap for repair of selected intraoral defects and to report our experience with this type of reconstructive procedure. The charts of 6 consecutive patients submitted to reconstruction of intraoral defects using the pedicled temporoparietal galeal flap were reviewed. All of the defects were located in the posterior oral cavity and oropharynx. After resection of the oral cancer, the temporoparietal galeal flap, based on the superficial temporal vessels, was raised and transposed to the mouth through a tunnel under the zygomatic arch. The oral defect was repaired, and no skin graft was applied over the flap. There were no flap losses, and the reconstructive goal was achieved in all cases. The patients' deglutition and phonation abilities were restored, and the donor site scars were well hidden by hair growth. The pedicled temporoparietal galeal flap is another option for selected cases of reconstruction of intraoral defects--mainly those located in the posterior oral cavity and oropharynx, in which thin and pliable tissues are usually required.