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9 Technical Tips inMicrovascular Surgery
91
9.6 Needle-Splint Technique
The “needle-splint” technique is a modication of the
continuous- interrupted suturing method described above
(see Sect. 9.5). This technical renement takes advantage of
the suture needle to ensure optimal eversion and alignment
of the vessel walls while maintaining visualization of the
intima.
• Step 1: Two interrupted sutures are applied proximal (0°)
and distal (180°) to the surgeon.
• Step 2: A loose running suture is then applied on the ante-
rior wall next to the rst suture and continuing until two
or three consecutive loose loops are created—this step
mimics continuous suturing, but the suture is left loose
and untied instead (Fig.9.5).
Fig. 9.5 The Needle-splint technique
• Step 3: The needle is inserted both through vessel walls
proximal to the created loose loops, but it is not passed
completely through to create a “splint.” The needle is then
used to manipulate the vessel walls ensuring optimal
positioning.
• Step 4: Starting from the rst, the loops are tied successively. The ends of each suture should be cut to avoid
multiple long ends in the anastomotic eld (Fig.9.5). The
needle is pushed through completely and the nal knot is
tied.
9.7 Crater Arteriotomy Technique
In cases of vessel-size discrepancy, an end-to-side microvascular anastomosis is preferred over the conventional end-toend method. The “crater” arteriotomy technique is a type of
excision arteriotomy (from outside in) for the side vessel that
allows direct visualization of the intimal surfaces during
suturing. This technique can prevent complications resulting
from intimal injury, such as thrombus formation and consequent ap failure.
• Step 1: The adventitia layer of the “side” vessel is dis-
sected off using curved microsurgical scissors (Fig.9.6a).
• Step 2: The vessel wall is gripped using the microsurgical
forceps in left hand and tented upward. A V-shaped shallow cut is made at about a 30–45° angle using adventitia
scissors in right hand. The cut is then deepened (30–50%
abc
def
Fig. 9.6 (a–f) The crater arteriotomy step-by-step technique
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M. Nicolaides and G. Patanis
of vessel thickness or until blood is seen to extravasate)
(Fig.9.6b, c).
• Step 3: The microsurgical forceps in left hand are used to
gently lift the tip of the V-shaped cut and pull it to the left
at a 45° angle. The scissors in right hand are used with the
concave side down to extend the cut at each side of the
“V” (Fig.9.6d, e).
• Step 4: The two cuts should eventually meet, creating a
biconvex/oval hole in the vessel wall (Fig.9.6f).
9.8 End-to-Patch Technique
End-to-patch technique is a microvascular pedicle modication for free ap transfer that utilizes the “mother” vessel
wall to enlarge and increase the caliber of the free ap pedicle. It can be used in either arterial or venous pedicles, and
the technique can be used to upscale a pedicle caliber to any
size vessel directed by the recipients provided they are
smaller than the “mother” nominate vessel that gives off the
ap pedicle.
• Step 1: The pedicle is marked along with an elliptical
component of the “mother” vessels’ wall.
• Step 2: A full thickness vessel wall is cut along with the
pedicle to allow a perfect match to the recipient vessel.
• Step 3: The “mother” vessel is either sutured primarily—
ideally with an 8/0 or 7/0 microvascular suture or patch
grafted if this technique is applied to an arterial pedicle
(Fig.9.7).
9.9 Dealing withNon-spurting Recipient
Arteries
Non-spurting recipient arteries are often encountered during
free tissue transfer. These are conventionally shortened using
straight scissors at an appropriate distance judged by the
microsurgeon. This approach is usually successful but can
result in excessive shortening as estimating an appropriate
distance is challenging. Furthermore, it can cause intimal
separation in atherosclerotic arterial stumps. An alternative
technique has been described to minimize these limitations
by using circumferential excision and stepwise shortening.
• Step 1: A longitudinal cut is made in the vessel wall using
curved microsurgical scissors (Fig.9.8a, b).
• Step 2: Cutting is gradually continued until blood spurts
out, indicating that a healthy portion of the artery has
been reached (Fig.9.8c, d).
• Step 3: A microsurgical clamp is applied proximally
(Fig.9.8e).
Fig. 9.7 The end-to-patch arteriotomy technique—a step-by-step guide
9 Technical Tips inMicrovascular Surgery
93
Fig. 9.8 (a–f) Step-by-step Miyamoto non-spurting test
• Step 4: The distal vessel wall is trimmed with circumfer-
ential excision (Fig.9.8f).
9.10 Dealing withLarge Vessel-Size
Discrepancy
Vessel-size discrepancy is common in microvascular anastomosis. It interrupts laminal blood ow, predisposing the anastomotic site to thrombi formation. Several techniques have been
described to address small- to medium-size discrepancy, including mechanical dilation, end-to-side anastomosis, sleeve anastomosis, and miscellaneous methods such as grafts, adhesives,
and couplers. For large vessel-size discrepancies, geometrical
techniques seem to be more promising. Below we describe the
“sh-mouth” and “sliced-pants” geometrical techniques.
9.11 Fish-Mouth Microvascular
Anastomosis Technique
• Step 1: Mark the 12 and 6 o’clock position on the vessel
circumference in a similar manner as the bi-angulation
technique (Fig.9.9a).
• Step 2: With a sharp straight micro-scissors, cut full thick-
ness to allow upscaling of the vessel caliber diameter
(Fig.9.9b).
• Step 3: The tiny sharp triangles are smoothened to allow a
more linear vessel caliber diameter and unify the vessel
circumference (Fig.9.9c).
• Step 4: The vessel has been upscaled and allowed an
increase in diameter (Fig.9.9d).
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M. Nicolaides and G. Patanis
Fig. 9.9 (a–d) Fish-mouth microvascular anastomosis step-by-step technique
abc
Fig. 9.10 (a–c) The sliced-pants technique
9.12 Sliced-Pants Technique
• Step 2: The adjacent vessel walls of the two branches are
incised to remove about 15–20% of the diameter of each
• Step 1: Identify a branched donor vessel. The total diameter of the two branches should be slightly larger than the
diameter of the recipient vessel (Fig.9.10a).
vessel (Fig.9.10b).
• Step 3: The two open vessels are sutured together to pro-
duce a single vessel of larger caliber (Fig.9.10c).
9 Technical Tips inMicrovascular Surgery
95
References
1. Lin SJ, Lee BT.The intrinsic tying platform in microsurgery. Plast
Reconstr Surg. 2009;123(6):223e–4e.
2. Fuse Y, etal. “Quadrupod” Grip for Handling Supermicrosurgical
Instruments. J Reconstr Microsurg. 2019;35(5):e1–2.
3. Chen H-C, etal. “Airborne” suture tying technique for the microvascular anastomosis. Plast Reconstr Surg. 2004;113(4):1225–8.
4. Agko M, etal. “Airborne” suture tying technique: simple steps to
make it easy. Head Neck. 2017;39(12):2558–61.
5. Nikkhah D, Patanis G.Posterior wall rst anastomosis for replantation. Plast Reconstr Surg. 2020;146(6):827e. https://journals.lww.
com/plasreconsurg/Fulltext/2020/12000/Posterior_Wall_First_
Anastomosis_for_Replantation.54.aspx.
6. Harris GD, et al. Posterior-wall-rst microvascular anastomotic
technique. Br J Plast Surg. 1981;34:47. https://www.jprasurg.com/
article/0007- 1226(81)90096- 5/pdf.
7. Sapountzis S, et al. A novel “continuous-interrupted” method for
microvascular anastomosis. Microsurgery. 2014;34(1):82–4.
8. Patanis G, etal. The “needle-splint” technique: a method of accurate apposition and eversion during microvascular anastomosis.
Plast Reconstr Surg Glob Open. 2020;8(1):e2611.
9. Patanis G, etal. The “crater” arteriotomy: a technique aiding precise intimal apposition in end-to-side microvascular anastomosis.
Plast Reconstr Surg Glob Open. 2020;8(10):e3014.
10. Lim SY, etal. End-to-patch anastomosis for microvascular transfer of free aps with small pedicle. J Plast Reconstr Aesthet Surg.
2015;68(4):559–64.
11. Miyamoto S, Fukunaga Y, Sakuraba M.Technical tips to trim the
stump of a nonspurting recipient artery. Plast Reconstr Surg Glob
Open. 2014;2(11):e248.
12. Harashina T, Irigaray A. Expansion of smaller vessel diameter by
sh-mouth incision in microvascular anastomosis with marked size
discrepancy. Plast Reconstr Surg. 1980;65(4):502–3.
13. Nicolaides M, Patanis G.Overcoming size discrepancy in microvascular anastomosis: the ‘sliced-pants’ technique. Ann R Coll
Surg Engl. 2022;104:234.
Part II
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Core Flaps
Temporal Artery Flaps
OliverJ.Smith, GregO’Toole, andWalidSabbagh
10
10.1 Introduction
The supercial temporal artery (STA) is the terminal branch
of the external carotid artery and it provides a rich arterial
supply to the tissues of the temporal fossa, forehead, upper
helix and scalp. The principal ap supplied by the STA is the
temporoparietal fascia ap. The TP or TPF ap involves the
tissue of the temporoparietal fascia (also known as the supercial temporal fascia). The use of fasciocutaneous tissue
supplied by the STA for reconstruction was rst described by
Monks [1] in 1898 for reconstruction of the lower eyelid.
However the TP ap was not popularised until the late twentieth century. It is a thin, pliable and richly vascular fascial
ap with a broad arc of rotation making it a versatile ap for
reconstruction of the scalp, face, mandible and oral cavity
[2]. The TP ap is most commonly used in auricular reconstruction as soft tissue coverage for cartilage-based or synthetic frameworks. It can be raised as an ipsilateral turndown
ap, or in rarer cases as a contralateral free tissue transfer. Its
rich vascularity makes it an ideal ap to support cartilage and
skin grafts and is therefore well suited to ear reconstruction.
It can also be used as a pedicled fascial ap for intraoral
defects [3] and has been described as a free ap in hand
reconstruction to allow tendon glide in full-thickness defects
[4]. The STA and accompanying vein can also be used as a
vascular pedicle for fasciocutaneous island aps of forehead
and temporal skin to reconstruct a variety of facial [5] and
scalp defects [6]. The ap can also be raised with calvarial
bone in rare cases for midface reconstruction [7].
O. J. Smith (*) · G. O’Toole · W. Sabbagh
Department of Plastic and Reconstructive Surgery, Royal Free
Hospital, London, UK
10.2 Anatomy
The external carotid artery splits into the STA and the maxillary artery anterior to the ear and within the substance of the
parotid gland. Before leaving the parotid gland, the STA
gives off the transverse facial artery which runs inferior to
the zygomatic arch to supply the masseter and lateral canthal
skin. The STA then courses superiorly over the zygomatic
arch within the substance of the temporoparietal (TP) fascia
where it can be palpated anterior to the tragus, before giving
off the middle temporal artery to the temporalis muscle. It
then divides above the arch into anterior (frontal) and posterior (parietal) branches. The anterior branch runs forwards to
supply the frontalis muscle and frontal scalp and is closely
related to the temporal branch of the facial nerve. The posterior branch runs superiorly towards the scalp vertex to supply
the parietal skin, periosteum and temporoparietal fascia. The
level of bifurcation above the arch of the STA can vary considerably; however in 90% of cases, it is within 2cm above
the tragus [8]. Reconstructive surgeons of the ear should be
aware that in the microtia ear, the STA has many anatomical
variations and commonly passes more anteriorly over the
zygoma than in the healthy ear [9]. The vessel in the microtia
patient can be atrophic and therefore difcult to palpate making preoperative planning more challenging.
The course of the supercial temporal vein (STV) is less
reliable and often runs apart from the artery. Bifurcation of
the STV is also not reliable, and it may continue as a single
branch, often running posterior to the artery after it has bifurcated [10]. Unreliability of the vein reduces the versatility of
free tissue transfer based on the supercial temporal pedicle
and is a consideration when planning to use the supercial
temporal vessels as donors for microvascular
reconstruction.
The temporoparietal fascia is a thin highly vascularised
layer that lies deep to, and is rmly adhered to, the brofatty
subdermal layer containing the hair follicles of the temporal
region. The TP fascia is continuous with the supercial mus-
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_10
99
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culoaponeurotic system (SMAS) of the face, the galea superiorly and the frontalis and occipital muscle anteriorly and
posteriorly. Deep to the TP fascia is a loose areolar layer
within which runs the temporal branch of the facial nerve.
This loose areolar layer separates the TP fascia from the deep
temporal fascia which overlies the temporalis muscle and
becomes continuous with the periosteum superiorly. At this
point there is a rich network of anastomotic vessels between
the supercial and deep temporal fascias, allowing incorporation of the deeper structures (muscle, periosteum, calvarium) into a ap based on the supercial temporal vessels
[11].
Anatomical variation in the vascular supply of the TP fascia is common. An anatomical study by Park etal. found that
the TP fascia was supplied by the STA as the dominant vessel in 88% of cases [12], with the remainder supplied by the
posterior auricular artery and occipital artery as the dominant
vessel. Venous drainage of the fascia is even more variable
with only 67% drained by the STV as the dominant draining
vessel. However, a TP ap is always raised on the STA as the
vascular pedicle. In situations where the STA is not palpable,
fascia could be raised on the other arteries, but these aps
would not be described as TP aps.
O. J. Smith et al.
Fig. 10.1 Picture illustrating the degree of hair shaving required when
using the TP ap for ear reconstruction
10.3 Preoperative Investigation
It is important to take a comprehensive history prior to surgical planning to identify any contraindications to TP ap
usage such as previous trauma, irradiation, surgery or carotid
artery pathology. The supercial temporal artery can be identied preoperatively by digital palpation and the position
conrmed with handheld Doppler. Care should be taken to
identify the main pedicle and both the anterior and posterior
branches. Preoperative imaging for the purposes of raising
the ap is not necessary.
10.4 Flap Design andMarkings
The positions of the main pedicle, anterior and posterior
branches, and the hairline are marked. The hair is shaved
along the course of the vessel and the planned incision
sites, although it may be prudent to shave a larger area in
ear reconstruction (Fig. 10.1). The fascial ap is most
commonly raised via a ‘Y’-shaped incision with a straight
limb anterior to the ear extending into a ‘Y’ shape superiorly to allow good exposure of the fascia. However several other incisions are described including a zigzag
incision favoured by one of our senior authors (Fig.10.2)
which has shown to improve postoperative scarring [13],
a horizontal straight line (Fig.10.3), two parallel lines, or
an incision around the ear to lift the pocket. The size of
Fig. 10.2 Picture showing the preoperative markings for a zigzag incision. Also marked are the anterior and posterior temporal artery
branches and the area of the TP fascia
Fig. 10.3 Picture showing the preoperative markings for a transverse
incision. Also marked are the anterior and posterior temporal artery
branches and the area of the TP fascia
10 Temporal Artery Flaps
the ap required should be marked on the fascia after the
initial skin raise and should be narrowed at the cephalic
end to avoid damage to the temporal branch of the facial
nerve. In rare instances where a fasciocutaneous ap is
required for skin defects, this is designed and marked on
the skin over the posterior branch. A TP ap based on the
anterior branch is rare due to the risk of brow ptosis and
unilateral forehead paralysis; however cutaneous island
aps can be raised on this vessel where non-hair bearingskin is required. If reconstruction of hair-bearing skin is
required, a 2–3-cm-wide pedicle can be easily closed, and
defects of up to 4×5cm have been described [14]; however skin defects larger than this may require preoperative
expansion.
101
10.5 Flap Elevation
• Step 1: Local anaesthetic inltration and hydro-dissection
of the supercial plane
Local anaesthetic is inltrated along the marked incision lines and within the supercial plane. This is a difcult plane to inject due to the adherence of the subcutaneous
fat to the fascia, but if the correct plane is found, this
assists in the dissection of this plane at the next step. The
key is to see subcutaneous spreading of the uid under the
skin. Hyalase can be added to the local anaesthetic mix to
help in developing the plane.
• Step 2: Incision and skin elevation (Fig.10.4)
After the initial incisions are made sharp, dissec-
tion is commenced at the level just deep to the hair
follicles. A plane can be found where the subcutaneous fat is adhered to the TP fascia, although identification of this plane can be difficult and care must be
taken to avoid damaging the hair follicles which may
lead to postoperative alopecia. The STA is located on
the surface of the fascia, and great care should be
taken in elevating the skin over the STA to ensure the
vessel is not damaged and included in the flap. The
veins (if present) are usually found within the subcutaneous fat.
• Step 3: Elevation of the posterior ap (Fig.10.5)
Once the TP fascia is exposed, the frontal branch of the
artery and any veins not included in the ap are ligated or
cauterised. Elevation of the posterior ap at the avascular
deep plane is then straightforward. The posterior ap is
raised superior to inferior, cauterising rare perforating
vessels to the deeper tissues as the ap raise advances.
The pedicle is then dissected caudally to the desired pivot
point.
Fig. 10.4 Picture showing the ap dissected free from the overlying
skin. Visible on the surface of the ap is the temporal artery
Fig. 10.5 Picture showing elevation of the posterior ap
10.6 Core Surgical Techniques inFlap
Dissection
• Step 1: Hydro-dissection
The authors’ preference is to use a dental local anaesthetic such as Lignospan (lidocaine with adrenaline). A
ne dental needle (30G) should be used to avoid damage
to vessels and the surgeon should not inject directly over
the vessels. The adrenaline will help to reduce bleeding
from the richly vascular subdermal scalp plexus during
skin dissection and allow a better view of the operative
eld. Local anaesthetic should be inltrated at least
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30min before surgery to give the adrenaline time to work.
Hyalase may be added to assist in developing the supercial plane. Injection directly over the vessel should be
avoided to prevent damage.
• Step 2. Skin elevation
Identication and careful preservation of the super-
cial temporal vessels as they traverse the subcutaneous fat
supercial to the fascia. The STV is especially vulnerable
as these pass posterior to the artery and in a more supercial plane [5]. These vessels must be dissected and traced
down to the pedicle anterior to the tragus. Therefore dissection under loupe magnication is recommended. The
authors recommend skin elevation to be undertaken with
a sharp scalpel or a Colorado needle on a low setting.
Dissection should be at the level just deep to the hair follicles. The use of bipolar cautery should be minimised to
avoid damaging hair follicles. If inclusion of an STV
branch is not possible, then the fascial cuff enveloping the
arterial pedicle should be kept a few centimetres wider to
allow venous drainage via the fascial venous network.
• Step 3. Posterior ap raise
The ap should be designed so that the caudal end is as
narrow as possible but also ensuring incorporation of the
pedicle and any veins. This allows the maximum arc of
rotation whilst also ensuring adequate vascular supply.
The pedicle should be dissected free of tethering tissue to
ensure a tension-free transfer to the recipient site.
If the surgeon requires bone, then this can be included
in the ap by preserving the desired width of fascial connection to the periosteum and deep temporal fascia (which
are continuous with each other) above the temporal line
which can be palpated at the cephalic border of the temporalis muscle. The outer table is then harvested using a
right-angled saw and curbed osteotome and the dissection
is then continued below this as outlined in step 3.
• Step 4: Closure and postoperative care
Direct, multilayered closure is achievable in most
cases. The authors recommend a ne absorbable suture
such as 5.0 monocryl to close the deep dermal tissue. Deep
sutures should be kept to a minimum as these can damage
hair follicles. An interrupted 5.0 nylon or prolene suture
should be used for the skin and removed at 7days. When
direct closure would lead to undue tension on the skin, a
V-Y skin ap advancement is used for closure. The authors
recommend the use of a low suction drain to prevent haematoma which can be removed 24h postoperatively.
10.7 Clinical Scenario
A TP ap is most commonly used in the second stage of
ear reconstruction where the auricular framework is elevated and the ap is used to provide additional soft tissue
O. J. Smith et al.
Fig. 10.6 Picture showing second stage ear reconstruction with cartilage framework release and skin insufciency requiring TP ap
coverage
Fig. 10.7 Picture showing coverage of cartilage framework with TP
ap and split skin graft
coverage, with a split thickness or full-thickness skin
graft used to provide nal skin coverage [15] (Figs.10.6
and 10.7). This technique can also be used to cover a polyethylene implant [16] although it is the authors’ preference to use an autologous technique. The ap may also be
used in cases of ear reconstruction where there is inadequate local skin to cover the auricular framework. This
may be the case in severe microtia where there is a deciency of the skin, or in cases of low hairline, previous
trauma, irradiation or secondary reconstruction where
previous surgery has failed leaving heavily scarred tissue
and a lack of skin.
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