Free flap transfer is commonly performed to reconstruct defects of the upper two-thirds of the face and scalp. Superficial temporal artery and vein have historically not been considered adequate. Use of the superficial temporal vessels for scalp and face reconstruction is reliable and safe.
Free flap transfer is commonly performed to reconstruct defects of the upper two-thirds of the face and scalp. Superficial temporal artery and vein have historically not been considered adequate. Use of the superficial temporal vessels for scalp and face reconstruction is reliable and safe.
Free flap transfer is commonly performed to reconstruct defects of the upper two-thirds of the face and scalp. Superficial temporal artery and vein have historically not been considered adequate. Use of the superficial temporal vessels for scalp and face reconstruction is reliable and safe.
Recipient Vessels for Facial and Scalp Microsurgical Reconstruction Scott L. Hansen, M.D. Robert D. Foster, M.D. Amarjit S. Dosanjh, M.D. Stephen J. Mathes, M.D. William Y. Hoffman, M.D. Pablo Leon, M.D. San Francisco, Calif. Background: Although free flap transfer is commonly performed to reconstruct defects of the upper two-thirds of the face and scalp, the superficial temporal artery and vein have historically not been considered adequate for microsurgical reconstruction and have rarely been described as recipient vessels. The purpose of this study was to determine the indications for and effectiveness of using the superficial temporal vessels for scalp and face reconstruction. Methods: Retrospective chart review on all patients undergoing microsurgical reconstruction for defects of the upper two-thirds of the face between 1996 and 2003 revealed45 free tissue transfers inwhichthe superficial temporal artery and vein were considered for use as recipient vessels. Flap success rates and post- operative course were evaluated. Results: Forty-three patients underwent 45 free flap transfers. The superficial temporal artery was used as the recipient artery in every case. In three cases, the superficial temporal vein was not suitable as the recipient vein and required use of a vein in the neck. The median length of follow-up was 4 years. Flap survival was 96 percent. Five patients required reoperation for vascular compromise. One of these patients ultimately had flap failure. In that patient, a subsequent attempt at microvascular flap reconstruction was successful using the same superficial temporal artery and vein as recipient vessels. Conclusions: Use of the superficial temporal artery and vein for scalp and face reconstruction is reliable and safe. The superficial temporal artery and vein should be considered as primary recipient vessels in microsurgical reconstruc- tion of the upper two-thirds of the face and/or scalp. (Plast. Reconstr. Surg. 120: 1879, 2007.) M icrosurgical free tissue transfer is now considered the standard for reconstruc- tion of defects resulting from tumor ab- lation, congenital abnormalities, or traumatic in- jury. The focus over the past two decades has shifted to optimizing this process. Experience has taught us that only a select number of donor sites are needed for the majority of reconstructions. For the upper two-thirds of the face and scalp, the rectus abdominis and latissimus dorsi muscles, andless commonly the scapular flap, provide great flap reliability and flexibility in restoring the nor- mal soft-tissue contour to the scalp and midface while obliterating the maxillary and/or orbital cavities when desired (Fig. 1). When thin resur- facing of the scalp is indicated, the radial forearm flap has been an ideal choice. 13 In contrast to donor-site selection, the optimal choice of recipient vessels for scalp and midfacial reconstruction is less well defined. When Schus- terman et al. reviewed their experience with 308 microsurgical reconstructions, they documented that greater than 90 percent of their recipient vessels were large-caliber vessels in the neck. 4 They felt that using large-caliber vessels enhanced their success rate. Subsequent studies by members of the reconstructive teamfromthe Memorial Sloan- Kettering Cancer Center have endorsed the need to use recipient vessels in the neck. 2,3,5 The rec- From the Division of Plastic and Reconstructive Surgery, University of California, San Francisco. Received for publication February 6, 2006; accepted June 15, 2006. Presented at the American Society for Reconstructive Micro- surgery meeting, in Palm Springs, California, January 15 through 18, 2005. Copyright 2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000287273.48145.bd www.PRSJournal.com 1879 ommended recipient vessels for flaps commonly included the facial, lingual, external carotid, su- perior thyroid, and superficial cervical arteries and their corresponding venous systems. How- ever, Cordeiro et al. also acknowledged that the long distance from the midface to the neck was a challenging aspect of free flap reconstruction. 3 Despite techniques to increase pedicle length, vein grafting may be necessary to span the 10 to 12 cm to the ipsilateral neck. 3 With all that has been written about head re- construction for defects of the upper two-thirds of the face, little has been written concerning the use of the superficial temporal artery and vein as re- cipient vessels. Hussussian and Reece used the superficial temporal vessels in less than one-third of their scalp reconstructions because they felt they were of insufficient caliber. 6 More recently, Lipa and Butler described the use of the superfi- cial temporal vessels in five of their six scalp re- constructions and advocated their use. 7 Moreover, a recent study reported using the temporal vessels in approximately 20 percent of their head and neck reconstructions. 8 To date, no center has evaluated a large group of patients undergoing microvascular free tissue transfer to the superficial temporal vessels. The purpose of this study was to determine the indi- cations for and the effectiveness of using the su- perficial temporal vessels for microvascular face and scalp reconstruction. In addition, we document techniques to optimize the use of these vessels. PATIENTS AND METHODS A retrospective chart review was performed on all patients with defects of the scalp and upper two-thirds of the face who underwent microsurgi- cal reconstruction with free flap transfer between January of 1996 and December of 2003 at the University of California, San Francisco and affili- ated hospitals. From that group of patients, those cases in which the superficial temporal artery and vein were used as recipient vessels were further analyzed and form the basis for this study. Appro- priate University of California, San Francisco Committee on Human Research approval was ob- tained before this study. Patient gender and age, cause and size of the defect, flap choice for re- construction, anastomotic technique, method of flap monitoring, postoperative course, and com- plications were recorded. RESULTS Between January of 1996 and December of 2003, 257 consecutive patients underwent micro- surgical head and neck reconstruction. Of these, 45 microsurgical tissue transfers to the superficial temporal vessels were attempted in 43 patients after they were evaluated preoperatively to have a palpable superficial temporal artery. Seventy-one of 257 patients that underwent microsurgical re- construction had defects in the scalp/midface re- gion. Of these 71 patients, 12 had defects in the parotid or ear region and thus the superficial tem- Fig. 1. (Left) Preoperativeviewof a manwitha posterior scalpdefect demonstrates theextent of thedefect after a failed local ap. (Right) Postoperative view several months after successful latissimus dorsi ap and skin grafting. Plastic and Reconstructive Surgery December 2007 1880 poral vessels were not suitable for microsurgical reconstruction purposes. The superficial tempo- ral artery and vein were not used in 14 of 59 patients who had defects in the orbit/midface and their flap was better positioned if the vessels in the neck were used. This resulted in 45 of 59 patients (76 percent) having their superficial temporal ar- tery and vein used for scalp/midface reconstruc- tion. There were 24 male and 21 female patients. The ages of the patients ranged from2 to 91 years, with a median age of 63 years. The areas of re- construction included scalp (n 19), orbit (n 4), skull base (n 4), midface (n 4), and orbital and midface (n 14) defects. The tissue trans- ferred included the rectus abdominis (n 23), radial forearm(n 9), latissimus (n 8), scapular flap (n 4), and serratus (n 1) and was based on the size and contour of the defect (Table 1). The volume of our defects ranged from 32 cm 3 to 500 cm 3 , with a mean defect size of 129 cm 3 . Twenty- eight of the patients (65 percent) had undergone previous radiation therapy. All anastomoses were performed in an end-to-end fashion using inter- rupted 9-0 nylon suture. Bony replacement was not necessary for any of the reconstructions. Be- ginning in 2000, the majority of our patients had an implantable Doppler device placed around the recipient veindistal to the venous anastomosis that provided continuous flap monitoring for 5 to 7 days postoperatively. Neither dextran nor heparin was routinely administered postoperatively. Only patients who required take-back for anastomotic complications were given heparin following the vascular revision. In all 43 patients, the main trunk of the su- perficial temporal artery was used as the recipient artery. There was minimal atherosclerosis notedin the superficial temporal artery for all patients. In 40 of the patients, we were able to identify the main trunk of the superficial temporal vein, and it had a less than 2:1 discrepancy with the donor vein from the flap. In these situations, the super- ficial temporal vein was used as the recipient ves- sel. Three of the 43 patients had a greater than 2:1 discrepancy between the donor vein and the su- perficial temporal vein on initial exploration. In these three patients, an ipsilateral external jugular vein, ipsilateral retromandibular vein, or con- tralateral facial vein was used; the latter two re- quired interposition vein grafts. The overall flap survival rate was 96 percent. The overall compli- cation rate was 31 percent (Table 2). Five patients (11 percent) required a return to the operating room for vascular compromise. All flaps requiring vascular revision were taken back to the operating room within 24 hours. Two of these patients were monitored with an implantable Doppler device and were returned to the operating room within 2 hours of identifying a change in the Doppler signal. Two of the five patients were noted to have an arterial thrombosis, and their anastomosis was revised. The other three patients experienced a venous thrombosis at the anastomotic site. Of these three patients, one required a revision of the anastomosis. Asecond patient had the venous out- flow revised with an interposition vein graft to the facial vein. The third patient with venous obstruc- tion, in addition to revision of their venous anas- tomosis with the superficial temporal vein, had venous outflow optimized with the use of a vena comitans of the superficial temporal artery. There were no anatomical problems noted in the recip- ient veins in the three patients who experienced a venous thrombosis. Moreover, we did not see any correlation between venous thrombosis and pres- ence of a suitable superficial temporal vein. The three patients who had venous thrombosis were Table 2. Complications (n 14) Complications No. Venous thrombosis 3 Arterial thrombosis 2 Hematoma* 5 Late flap loss 1 Cellulitis 1 Necrosis of rectus skin island 2 *Two of five hematomas occurred after the patients were anticoag- ulated following reexploration because of vascular compromise. This flap loss was attributable to the patient wearing glasses post- operatively. Cellulitis occurred at the inferior portion of a flap. These skin islands had been debulked with liposuction. Table 1. Choice of Flap by Site of Reconstruction in 43 Patients Site of Reconstruction No. of Flaps Scalp (n 19) Latissimus 8 Radial forearm 5 Rectus 3 Scapular 3 Orbit and midface (n 14) Rectus 13 Scapular 1 Orbit only (n 4) Rectus 4 Midface only (n 4) Rectus 1 Serratus 1 Radial forearm 2 Skull base (n 4) Rectus 2 Radial forearm 2 Volume 120, Number 7 Temporal Vessels for Reconstruction 1881 different fromthe three patients who did not have sufficiently large superficial temporal veins and required the use of veins in the neck. The second patient with flap loss initially had arterial throm- bosis that required revisionof the anastomosis and the flap ultimately failed after a hematoma devel- oped under the flap after the patient was antico- agulated following the first reoperation. The over- all complication rate was 31 percent. The length of follow-up ranged from3 months to 8 years, with an average of 4 years. Two flaps (4 percent) in this series failed. One was a patient that initially required take-back for arterial throm- bosis resulting from arterial kinking. After this take-back, the patient was started on heparin and developed a hematoma under the flap. This flap subsequently failed and the patient underwent re- construction with another flap performed to the same superficial temporal vessels without further adverse sequelae. A second patient developed flap failure during the perioperative period despite being discharged to home with a viable flap. Fur- ther evaluation determined that the patient used her eyeglasses (constricting the vascular pedicle), despite instructions to the contrary. This patient successfully underwent a second microvascular re- construction using the facial vessels. DISCUSSION The ability to provide immediate reconstruc- tion for large defects of the scalp and face has significantly improved the quality of life for many patients. Refining donor-site selection has further improved results. 13,57 For the upper two-thirds of the face, where bone flaps are rarely necessary, the radial forearm, rectus abdominis, and latissimus dorsi flaps are our flaps of choice. For coverage of large wounds, the rectus abdominis and latissimus dorsi musculocutaneous flaps are preferred. These flaps are effective in skull base coverage, particularly after a dural resection and repair where muscle bulk is important to adequately pro- tect the repair. The thin, broad muscle of the latissimus flap (in combination with skin grafting) is especially well suitedafter largescalpresections. 7 For small defects, the radial forearm fasciocutaneous flapprovides thin, pliableskinwithlimitedsoft-tissue bulk, characteristics that make it ideal for resurfac- ing the cheek and scalp. Historically, concerns about vessel diameter and supplying enough blood to support flaps with a large surface area have limited the use of the superficial temporal vessels for head and neck re- construction. In contrast to previous reports, our series suggests that virtually all flap reconstruc- tions to the scalp and midface can be successful using the superficial temporal vessels no matter which flap is used. Anatomical studies in the lit- erature examining vessel diameters in the head and neck suggest that the difference in vessel di- ameters of the superficial temporal and facial ar- tery and vein may not be as significant, on average, as has been understood. 9,10 We have found the anatomical course of the superficial temporal vessels to be very reliable and consistent with the descriptions in the literature. The superficial temporal artery is one of the ter- minal branches of the external carotid artery. It begins in the substance of the parotid gland, be- hind the neck of the mandible, and crosses over the root of the zygomatic process of the temporal bone. It consistently divides into two major branches: the frontal and parietal branches. 9,11 The recipient arterial anastomosis inour study was always at the main trunk of the superficial tem- poral artery, anterior to the tragus, before the branch point (Fig. 2). The spectrum of size dis- crepancies between recipient and donor vessels ranged from 1:1 to 1:2. We were able to accom- modate the size discrepancies between recipient and donor arteries for all patients. The same su- perficial temporal artery and vein were used in one patient whose flap failed after initial difficul- ties with the arterial anastomosis, in the subse- quent free flap reconstruction. The superficial temporal vein demonstrates more variability with respect to its branching pat- Fig. 2. Intraoperativedemonstrationof thesupercial temporal artery and vein dissected just anterior to the tragus. Plastic and Reconstructive Surgery December 2007 1882 tern (it can divide into one, two, or three major branches) and its relationship to the superficial temporal artery. 11 Park et al. noted that the su- perficial temporal artery and vein ran in parallel to supply temporoparietal flaps in only 63.4 per- cent of patients studied. The remainder had ve- nous drainage through the posterior auricular, occipital, or diploic veins. 9 In cadaver studies, it was noted that the major branches of the super- ficial temporal vein were different from those of the superficial temporal artery. The thin parallel veins to the superficial temporal artery are venae comitantes. 11 However, we overcome this variabil- ity by performing the venous anastomosis using either the closest branch to the superficial tem- poral artery or, more reliably, to the main trunk of the superficial temporal vein at its initial branch- ing point. During the initial operation, we were not able to identify a suitable recipient vein in three patients. In these cases, a suitable recipient vein in the neck was used. Two of these patients required a vein graft to bridge the distance. The primary use of the superficial temporal vessels ob- viates the need for a longer pedicle or vein graft. Although vein grafting does not decrease overall flap survival, it necessitates the use of additional donor sites and has been associated with a higher revision rate. 8 As our experience with the superficial tempo- ral artery and veinincreased, we have made several modifications to our technique. Preoperatively, we evaluate for the presence of the superficial temporal artery by direct palpation and Doppler imaging if a pulse is not easily identified. Other preoperative imaging studies are not performed. Intraoperatively, we always explore the superficial temporal artery and vein by means of a face-lift incision before looking for an alternative in re- construction involving the upper two-thirds of the face or scalp. After gross dissection, we perform the majority of our vessel preparation under the operating microscope. To avoid spasm, we handle the vessels minimally and inject papaverine into the adjacent adventitia with a 30-gauge needle. The adventitia of the artery and vein is minimally stripped. All patients routinely receive an implant- able venous Doppler device for postoperative vas- cular monitoring. Althougharterial monitoring of the superficial temporal vessels is possible without the use of an implantable Doppler device, arterial monitoring does not allow for rapid detection of venous thrombosis, as an arterial pulse will persist for as long as several hours after venous throm- bosis. By the time the arterial signal is lost, salvage of the flap is less likely. In addition to postoper- ative vascular monitoring, the Doppler device has been valuable during closure of the recipient site. The strain being placed on the pedicle by the closure can be monitored directly by the venous Doppler device and the closure can be adjusted as needed. Since adopting this practice, no flaps have failed during the immediate postoperative period. Our overall complication rate of 31 percent is comparable to previous studies that have docu- mented an overall complication rate ranging from 17.5 to 59 percent. 1,2,46 Other than administra- tion of daily aspirin begun immediately postoper- atively, blood thinners (heparin, dextran) are not part of the routine postoperative care. The venous Doppler device is used for 5 to 7 days. CONCLUSIONS The superficial temporal vessels are reliable and safe recipient vessels for microsurgical recon- struction of the upper two-thirds of the face and scalp. Free tissue transfer was successfully carried out in a patient as young as 2 and a patient as old as 91 years. Flap perfusion was adequate for mus- cles as large as the latissimus dorsi and defects as large as 500 cm 3 . Incorporation of the principles presented has allowed us to reliably reconstruct the middle to upper face and scalp by a simpler approach compared with previously described series. Scott L. Hansen, M.D. Division of Plastic Surgery Surgical Research Division, Box 1302 University of California, San Francisco San Francisco, Calif. 94131-1302 shansen@sfghsurg.ucsf.edu DISCLOSURE None of the authors has any financial interests re- garding the products, devices, or drugs mentioned in this article. REFERENCES 1. Foster, R., Anthony, J., Singer, M., et al. Reconstruction of complex midfacial defects. Plast. Reconstr. Surg. 99: 1555, 1997. 2. Disa, J., Pusic, A., Hidalgo, D., et al. Simplifying microvas- cular head and neck reconstruction: A rational approach to donor site selection. Ann. Plast. Surg. 47: 385, 2001. 3. Cordeiro, P., and Disa, J. Challenges in midface reconstruc- tion. Semin. Surg. Oncol. 19: 218, 2000. 4. Schusterman, M., Miller, M., Reece, G., et al. Asingle centers experience with 308 free flaps for repair of head and neck cancer defects. Plast. Reconstr. Surg. 93: 472, 1994. 5. Hidalgo, D., Disa, J., Cordeiro, P., et al. A review of 716 consecutive free flaps for oncologic surgical defects: Refine- Volume 120, Number 7 Temporal Vessels for Reconstruction 1883 ment in donor-site selection and technique. Plast. Reconstr. Surg. 102: 722, 1998. 6. Hussussian, C., and Reece, G. Microsurgical scalp recon- struction in the patient with cancer. Plast. Reconstr. Surg. 109: 1828, 2002. 7. Lipa, J., and Butler, C. Enhancing the outcome of free la- tissimus dorsi muscle flap reconstruction of scalp defects. Head Neck 26: 46, 2004. 8. Nahabedian, M., Singh, N., and Deune, E. G. Recipient vessel analysis for microvascular reconstruction of the head and neck. Ann. Plast. Surg. 52: 148, 2004. 9. Park, C., Lew, D., and Yoo, W. An analysis of 123 temporopa- rietal fascial flaps: Anatomic and clinical considerations in total auricular reconstruction. Plast. Reconstr. Surg. 104: 1295, 1999. 10. Zhao, Z., Li, S., Xu, J., et al. Color Doppler flow imaging of the facial artery and vein. Plast. Reconstr. Surg. 106: 1249, 2000. 11. Imanishi, N., Nakajima, H., Minabe, T., et al. Venous drain- age architecture of the temporal and parietal regions: Anat- omy of the superficial temporal artery and vein. Plast. Re- constr. Surg. 109: 2197, 2002. Online CME Collections This partial list of titles in the developing archive of CME article collections is available online at www. PRSJournal.com. These articles are suitable to use as study guides for board certification, to help readers refamiliarize themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old can be taken for CME credit. Reconstructive Head and Neck The Role of Open Rhinoplasty in the Management of Nasal Dermoid CystsRod J. Rohrich et al. The Evolution of the Hughes Tarsoconjunctival Flap for Lower Eyelid ReconstructionRod J. Rohrich and Ross I. S. Zbar Subunit Principles in Midface Fractures: The Importance of Sagittal Buttresses, Soft-Tissue Reductions, and Sequencing Treatment of Segmental FracturesPaul Manson et al. Microsurgical Replantation of the Amputated NoseDennis C. Hammond et al. Advances in Head and Neck ReconstructionGeoffrey C. Gurtner and Gregory R. D. Evans Auricular Reconstruction: Indications for Autogenous and Prosthetic TechniquesCharles H. Thorne et al. Reconstruction of the CheekFrederick J. Menick Management of the Recurrent, Benign Tumor of the Parotid GlandDavid L. Larson The Superiorly Based Nasolabial Flap for Simultaneous Alar and Cheek ReconstructionRod J. Rohrich and Matthew H. Conrad Pharmacologic Optimization of Microsurgery in the New MillenniumMatthew H. Conrad and William P. Adams, Jr. Understanding the Nasal Airway: Principles and PracticeBrian K. Howard and Rod J. Rohrich Auricular Reconstruction for Microtia: Part I. Anatomy, Embryology, and Clinical EvaluationElisabeth K. Beahm and Robert L. Walton Auricular Reconstruction for Microtia: Part II. Surgical TechniquesRobert L. WaltonandElisabethK. Beahm Rhinophyma: Review and UpdateRod J. Rohrich et al. Velopharyngeal Incompetence: A Guide for Clinical EvaluationDonnell F. Johns et al. Basal Cell Carcinoma: An Overview of Tumor Biology and TreatmentDavid T. Netscher and Melvin Spira Nasal Reconstruction: Forehead FlapFrederick J. Menick Reconstruction of Acquired Scalp Defects: An Algorithmic ApproachJason E. Leedy Further Clarification of the Nomenclature for Compound FlapsGeoffrey G. Hallock Current Options in Head and Neck ReconstructionKeith A. Hurvitz et al. Plastic and Reconstructive Surgery December 2007 1884