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10 Temporal Artery Flaps
103
10.8 Pearls andPitfalls
Pearls
• Use Doppler to accurately mark the position of the
vessels preoperatively due to the wide variation in
vessel anatomy.
• Skin incision can be sloped in direction of hair follicles to minimise risk of alopecia.
• The undersurface of the ap is a safe zone and can
be dissected very easily.
• Venous drainage often the problem therefore tries to
include a posterior vein or keep the base of the ap
as wide as possible.
• Take extra care during skin raise to avoid hair follicle damage. The use of hydro-dissection will assist
this.
Pitfalls
• The ap may be more appropriate in girls with long
hair as this helps to hide the scar and any alopecia.
Boys with shorter hair are more likely to have more
visible scarring.
• There is also a higher risk of unsatisfactory postoperative scarring in those with fairer hair compared
to darker hair.
• Scars can stretch leaving an unsatisfactory cosmetic
outcome.
• There is high risk of vessel damage during ap
elevation.
• There is risk of temporal branch of facial nerve
injury during elevation of the anterior ap.
10.9 Selected Readings
• Park C, Lew D-H, Yoo W-M.An analysis of 123 temporoparietal fascial aps: anatomic and clinical considerations
in total auricular reconstruction. Plast Reconstr Surg.
1999;104:1295–306.
A comprehensive clinical and anatomical analysis of
one units extensive experience in using TP aps for auricular reconstruction.
• Nagata S. A new method of total reconstruction of the
auricle for microtia. Plast Reconstr Surg.
1993;92(2):187–201.
Seminal paper on microtia reconstruction.
• Nagata S. Secondary reconstruction for unfavorable
microtia results utilizing temporoparietal and innominate
fascia aps. Plast Reconstr Surg. 1994;94:254–65.
Pioneer of ear surgery discussing the use of TP aps in
complex and redo microtia surgery.
• Gillies HD.Plastic surgery of the face. NewYork, NY:
Gower Medical Publishing Ltd; 1983.
Classic text from the father of plastic surgery who outlines the use of pedicled island aps based on the supercial temporal vessels for facial reconstruction.
References
1. Monks GH.The restoration of a lower lid by a new method. Bost
Med Surg J. 1898;139:385–7.
2. Collar RM, Zopf D, Brown D, Fung K, Kim J.The versatility of the
temporoparietal fascia ap in head and neck reconstruction. J Plast
Reconstr Aesthet Surg. 2012;65:141–8.
3. Nayak VK, Deschler DG. Pedicled temporoparietal fascial
ap reconstruction of select intraoral defects. Laryngoscope.
2004;114(9):1545–8.
4. Upton J, Rogers C, Durham-Smith G, Swartz WM.Clinical applications of free temporoparietal aps in hand reconstruction. J Hand
Surg. 1986;11(4):475–83.
5. Elbanoby TM, Zidan SM, Elbatawy AM, Aly GM, Sholkamy
K.Supercial temporal artery ap for reconstruction of complex
facial defects: a new algorithm. Arch Plast Surg. 2018;45:118–27.
6. Tenna S, Brunetti B, Aveta A, Poccia I, Perichetti P. Scalp reconstruction with supercial temporal artery island ap: clinical experience on 30 consecutive cases. J Plast Reconstr Aesthet Surg.
2013;66:660–6.
7. Davison SP, Mesbahi AN, Clemens MW, etal. Vascularized calvarial bone aps and midface reconstruction. Plast Reconstr Surg.
2008;122:10e–8e.
8. Beheiry EE, Abdel-Hamid FA. An anatomical study of the temporal fascia and related temporal pads of fat. Plast Reconstr Surg.
2007;119(1):136–44.
9. Olcott CM, Simon PE, Romo T III, Louie W.Anatomy of the supercial temporal artery in patients with unilateral microtia. J Plast
Reconstr Aesthet Surg. 2019;72:114–8.
10. Ausen K, Pavlovic I. Flaps pedicled on the supercial temporal
artery and vein in facial reconstruction: a versatile option with a
venous pitfall. J Plast Surg Hand Surg. 2011;45:178–87.
11. Nakajima H, Imanishi N, Minabe T.The arterial anatomy of the
temporal region and the vascular basis of various temporal aps. Br
J Plast Surg. 1995;48:439–50.
12. Park C, Lew D-H, Yoo W-M.An analysis of 123 temporoparietal
fascial aps: anatomic and clinical considerations in total auricular
reconstruction. Plast Reconstr Surg. 1999;104:1295–306.
13. Tanaka A, Hatoko M, Kuwahara M, Yurugi S, Lioka H, Niitsuma
K.Evaluation of scars after harvest of the temporoparietal fascial
ap depending on the design of the skin incision. Ann Plast Surg.
2002;48(4):376–80.
14. Algan S, Kara M, Cinal H, Barin EZ, Inaloz A, Tan O. The
temporal artery island ap: a good reconstructive option for
small to medium- sized facial defects. J Oral Maxillofac Surg.
2018;76:894–9.
15. Nagata S.A new method of total reconstruction of the auricle for
microtia. Plast Reconstr Surg. 1993;92(2):187–201.
16. Tahir Y, Reinisch J. Porous polyethylene ear reconstruction. Clin
Plast Surg. 2019;46(2):223–30.
Supraorbital and Supratrochlear Artery
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Flaps - Forehead Flap and Modifications
DanielB.Saleh andAlexDearden
11
11.1 Introduction
The rst evidenced scripture of the forehead ap was
believed to be around 600BC, in India, in the ancient medical treatises the Sushruta Samhita [1]. Modern translation
reveals the description of the total nasal reconstruction was
derived from a cheek ap but nevertheless was the rst
description of a pedicled tissue transfer in contemporary
reconstructive terms.
The Italian Antonio Branca brought the forehead ap to
Europe in the fteenth century [2], but it was not until 1794
when J. C. Carpue read an editorial in The Gentleman’s
Magazine where its journey to become the workhorse for
nasal reconstruction began [3]. Following his intrigue in the
novel technique, he practised on cadavers for over 20years
before utilising it on two soldiers in 1814 [4].
Further renements were made, the most recent iterations
of which have been popularised by Burget and Menick in the
1980s [5–7] by narrowing the base of the paramedian ap for
greater arc of rotation and the safety of debulking the distal
ap supercial to the frontalis muscle. These have largely
been borne out of better anatomic understanding in conjunction with the reconstructive concepts of angiosomes, delay
and dermal blood supply.
11.2 Anatomy
Typically, four paired arteries supply the forehead skin:
• Angular, branching into the dorsal nasal and central
• Supratrochlear
• Supraorbital
• Supercial temporal and its terminal branches
D. B. Saleh (*)
Plastic and Reconstructive Surgery, Royal Victoria Inrmary,
Newcastle Upon Tyne, UK
A. Dearden
Royal Victoria Inrmary, Newcastle Upon Tyne, UK
Although orientated in an axial direction, the arborising
nature of these vessels makes a rich interconnecting network
of vascularity orientated in the glabella and medial canthal
region [8]. This has enabled the application of various aps
designs and their renements over the past century to address
a variety of reconstructive challenges in the facial, head and
neck regions.
Mangold’s injection study demonstrated that the median
and paramedian aps are positioned so that their main supply
is from the supratrochlear artery with additional lling from
the dorsal nasal and supraorbital arteries [9].
The supratrochlear artery is a terminal branch of the ophthalmic artery. It exits the superior medial orbit 1.7–2.2cm
lateral to the midline and continues a vertical course for
approximately 3cm at the medial position of the brow [8]. It
initially lies supercial to the corrugator supercilii muscle
but deep to the orbicularis and frontalis at the level of the
brow then traversing the frontalis to lie in the subcutaneous
tissues 1cm above the brow where the option of ap debulking is possible.
The paired dorsal nasal arteries usually merge after 5mm
to form a single central artery supplying the glabella and
inferior and middle transverse thirds of the central forehead
[10]. A recent histological study [11] suggests it is the central artery to be the prominent blood supply of the medial
forehead ap design challenging its nomenclature as a true
axial ap of the supratrochlear artery. The central artery
forehead ap is now well described in the contemporary literature [12].
The frontal (anterior) branch of the supercial temporal
artery enters the forehead at different transverse levels at the
lateral orbital rim. Once it crosses this line, it usually divides
into an ascending branch and a transverse branch of smaller
diameter at this level [10]. The anterior supercial temporal
artery is supercial to the temporalis muscle, and as it medialises it gradually becomes more supercial to a subdermal
level. The average diameter of the anterior supercial temporal artery is 2mm at the level of the lateral orbital rim [10].
Care must be taken to preserve the temporal branch on the
facial nerve which runs anteroinferiorly to the artery with
© 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_11
105
106
64% predictability; thus surgical precision is paramount in
this region to avoid neural injury [13].
The venous system is formed from the parallel supratrochlear and central veins. They converge over the glabella
to drain into the angular veins either side of the nose. The
central vein is often larger on one side of the forehead and
should also be incorporated into the ap design. Furthermore
it can aid as a landmark to decide which side of the forehead
to use to ensure optimal drainage.
11.3 Preoperative Investigation
Routine preoperative radiology is seldom required in planning these aps unless there has been signicant surgery in
the region and axial vascular supply is in question. In such
circumstances computed tomography with contrast can be
useful for identication of enhancing vessels along their
complete course and permits cross midline comparison to
correlate with previous scars.
Handheld Doppler examination with intensity of at least
8 Hz in the clinic will determine the presence of suitable
vessels that can be used for ap transfer. This can be augmented by use of infrared thermography (see stepwise ap
raising).
We have successfully transferred forehead aps in patients
with supercial scars from cutaneous malignancy resection
and even deep dermal/full-thickness burns. Specically, if
there is axial pulsation on Doppler examination, scars can be
incorporated into ap design in absolutely necessary.
However one must consider a delay procedure in the rst
incidence to maximise success in these rarer scenarios.
D. B. Saleh and A. Dearden
Fig. 11.1 A pre-templated and Dopplered paramedian forehead ap
for a hemi-nasal reconstruction. Templates were taken from the normal
contralateral side
11.3.2 The Anterior Supercial Temporal
Artery Flap
11.3.1 Flap Design andMarkings: Multistage
Forehead Flap
11.3.1.1 The Multistage Paramedian
ForeheadFlap
The relative focus of this description pertains to nasal reconstruction but can be translated to an array of periocular,
cheek and upper labial defects. An ipsilateral ap is better
suited to treating defects on the ipsilateral nose or face if
available.
The exact defect dimensions should be templated, and if
this is challenging due to major distortion and secondary
cicatrix, if available, the contralateral normal side should be
templated as a mirror image (Fig.11.1).
The multistage forehead ap tends to offer better functional and cosmetic outcomes in nasal reconstruction and the
opportunity to better control structural support introduced
into the repair.
This is a very useful forehead ap based on the anterior or
frontal division of the supercial temporal artery (STA)
ap. Lei and colleagues succinctly delineated the anatomy
and that whilst the ASTA is essentially constant, it can
vary in being a ‘high’ or ‘low’ type [13]. This ap incurs a
scar in the suprabrow, or anterior temporal region, but has
the versatility to reconstruct the periorbital and cheek
region. This is a myocutaneous ap to ensure reliable vascularity as the vessels at its medial course can be
intramuscular.
11.3.3 Flap Raise/Elevation: AStep-by-Step
Guide
11.3.3.1 The Multistage Paramedian
ForeheadFlap
Where possible place the patient in marginal head down
position supine to increase forehead blood ow and induce
temporary venous lling.
11 Supraorbital and Supratrochlear Artery Flaps - Forehead Flap and Modications
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1. Palpate the supratrochlear notch and place the handheld
Doppler over this area in the medial brow region.
2. Follow the pulsation cranially to outline the exact pathway of the vessel (Fig. 11.1). In anaesthetised patients
ensure they are normotensive. In the virgin forehead, it is
not critical to do this, but it does allow much more
accurate ap planning, reducing forehead wound morbidity and theoretically providing a more accurate wound
repair.
3. Reverse plan using a gauze to ensure the correct length of
ap is planned. Base your preformed template on the vessel axiality unless the hair pattern dictates a more lateral
placement. This is less critical in cases whereby the distal
ap is aimed at internal nasal lining, where hair growth is
accepted (Fig.11.1).
4. The proximal limits of the skin ap width need only to be
approximately 1–2cm centred over the Doppler signal;
this also allows easier rotation of the ap to the defect
(Fig.11.1).
5. The ap is raised in a distal to proximal (cranial to caudal) fashion incising the skin, subcutaneous fat and frontalis muscle down to the periosteum. The upper two-thirds
alone are incised initially. Blade dissection is preferable
but monopolar cautery can also be used with low setting
for the coagulation in order to protect the periosteum to
permit maximal healing potential without desiccation.
6. Once this portion of the ap is raised, use the on-table
Doppler to ensure the signal is present in the ap. Whilst
Fig. 11.2 The ap turned down caudally revealing the periosteum with
denuded frontal bar and intact periosteum cranially
this is not vital, with minimal fuss, it only takes 30–40s
to do and avoids the rare situation whereby anomalous
anatomy is encountered.
7. Once the position of the vessel has been rechecked, the
remaining skin incisions are made through the skin, and
at the base of the wound, the periosteum is incised to continue in the sub-periosteal plane (Fig. 11.2). An
(b) Emerging through a foramen, which may require a
2mm osteotome to free the vessels (Figs.11.4 and
11.5)
(c) Emerging through a ligamentous foramen where the
ligament can be divided with a Mitchell’s trimmer
Obwegeser elevator is gently used to lift the periosteum
with the bevel facing the bone. Then blunt dissection with
11.3.3.2 Point forConsideration
a Jameson or littler scissors will tease the bres of the
frontalis, procerus and corrugator supercilii to reveal the
underlying periosteum at the medial and lateral extents of
the ap edges. It is our preference to do this bluntly,
because occasionally draining veins can be favourable
placed in the arc of rotation for the ap; hence there is no
need for ligation of these medial intramuscular veins
unless they impede eventual ap transfer.
8. Once the skin and muscle dissection has reached the brow
and the ap is liberated, the sub-periosteal dissection continues with care around the medial supraorbital bar where
the vascular pedicle can be visualised in three typical
congurations (Fig.11.3):
(a) Emerging from a supraorbital notch where the ves-
sels are freely mobile with gentle caudal
displacement
There is a variety of postulation, pontication and assertion
regarding the need to see and mobilise the vessels in the
above fashion. It is our preference to take the ap caudal to
the brow to allow ease of rotation to the nasal defect. In the
majority of cases, this requires one of the above manoeuvres
to succeed. However, for cranial nasal defects, or eyelid/
cheek resurfacing (for a contralateral forehead ap), a wellplanned ap may avoid the need for dissection that involves
seeing the pedicle, and thus, the ap could be regarded as
agnostic with reference to the vascular pedicle. It is also reasonable to state avoiding dissection around (not of) the pedicle reduces the risk of inadvertent injury, compromising the
reconstructive efforts. In general a cut as one goes principle
for locoregional reconstruction is useful when one knows
there is an axial supply within the ap.
107
108
D. B. Saleh and A. Dearden
Fig. 11.3 Flap released from supraorbital bar over the medial brow
Fig. 11.5 2mm osteotome to open the frontal foramen
A counterargument we, and others, would highlight is
that in certain circumstances (e.g. a hemi-nasal reconstruction), inadequate caudal dissection and thus rotation of the
ap may manifest itself as vascular (venous) kinking, also
compromising the blood supply. So overall, with due care
and attention, vascular visualisation, without overt pedicle
dissection, is our preference.
9. The ap is now free to be transferred to the recipient site.
We like to oppose the donor wound just above the brow
rst (Fig.11.6), to align the brows correctly and ensure
this does not cause any unusual ap compromise. It is
frustrating to recognise the brows are mal-aligned following meticulous inset of the ap at the recipient site.
11.3.4 Anterior Supercial Temporal
ForeheadFlap
11.3.4.1 Patient Preparation, Marking
andSurgery
Fig. 11.4 Neurovascular structures emerging from a foramen; the yel-
low arrow depicts a retracted medial branch of the supratrochlear nerve,
and the blue arrow shows the main vascular pedicle, with minor contributing venous branches laterally
1. Doppler examination starting pre-auricular and distal
course is followed into the forehead/brow region depending on ‘high/low’ variant.
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Fig. 11.7 Raised anterior supercial temporal artery ap in a facial
reconstruction for a rst-stage upper and lower eyelid reconstruction
11.3.5 Transverse Temporal Forehead Flaps
In keeping with the principles described above, the whole
forehead (or parts of) unit can be raised in the submuscular
plane for a variety of facial and intraoral defects, the latter
typically being in a two-stage fashion requiring pedicle division after 3 weeks. This approach, whilst uncommon, has
distinct advantages, in particular where facial salvage is
paramount:
109
Fig. 11.6 Brow inset rst (one or two sutures) followed by nasal inset
2. Ideally aim for direct closure—skin pinch to assess viability of direct closure and reverse plan the arc of the ap.
3. ‘Zig-zag’ or curvilinear incision over temporal course of
the vessel, with skin aps raised in subcutaneous plane
until islanded incisions are made. Or in cases where lid
reconstruction does not warrant signicant pedicle mobilisation, we recommend a medial to lateral cut as you go
approach to limit incisions made. This is preferred in case
remedial facial procedures are required, or in patients in
cutaneous malignancy where tissue preservation is more
preferable (Fig.11.7).
4. The islanded ap is then incised to include the caudal
portion of the frontalis and bluntly dissect through the
corrugator supercilii and orbital portions of the orbicularis oculi muscle to reach the areolar submuscle plane.
Medially this plane is more adherent, and care must be
taken to preserve the periosteum and supratrochlear/
orbital neurovascular bundles.
5. The ap can then be raised in this plane from medial to
lateral. At the lateral brow region, the dissection is blunt
in the muscular plane to preserve terminating branches of
the frontal nerve.
1. Midfacial and lower facial defects whereby the ‘cranial’
direction of scar and contracture of the ap is favourable
to support the soft tissues and prevent unfavourable
downward pull as seen in similar aps from the upper
chest to the lower face. Or from midfacial tissues to the
lower eyelids.
2. In intraoral or facial tumour cases whereby a microsurgical solution is either not possible or has been used to
maximal effect, for example, a patient who has had
numerous oropharyngeal resections, free tissue transfers
and radiation therapy (Figs.11.8 and 11.9).
11.3.6 Core Surgical Techniques inFlap
Dissection
11.3.6.1 Staged Considerations: Nasal
Reconstruction
Prior to commencing nasal reconstruction, adjacent but contiguous defects in the eyelid(s), upper lip and cheek(s) must
be repaired rst to provide a stable surrounding framework
for the nose. In certain cases, such as skin cancer cutaneopaths, in whom facial skin is in short supply, the forehead
ap can be used for marginal medial cheek restoration at the
110
D. B. Saleh and A. Dearden
Fig. 11.8 A total forehead unit transverse ap raised on the left supercial temporal artery
same time as nasal reconstruction as a compromise
(Figs.11.10 and 11.11). However for the majority, it is better
to restore surrounding anatomy in the rst instance, or in the
same procedure as the rst nasal stage, but using alternate
tissue sources (Fig.11.12).
A particular consideration is the timing of cartilage graft-
ing. In general it is our preference to:
1. Primarily place grafts where good lining already exists
(Fig.11.12)
2. Secondarily place grafts in intermediate stage(s) where
the forehead ap or another form of tissue is deployed for
lining in preliminary/rst stages of reconstruction
(Figs.11.13, 11.14, and 11.15)
C
Fig. 11.9 Wide ap arc of rotation and can be tunnelled through the
nasolabial region to close intraoral defects, such as the oor of the
mouth in this case
11.3.6.2 Intermediate Stages
After approximately 1 month, the ap at the recipient site
can be safely elevated and thinned and allow the placement
of cartilage grafts. Intermediate stages offer the excellent
opportunity to sculpt soft tissue and accurately amend and
augment structural support (Fig.11.16).
11.3.6.3 Final Stage
Division of the pedicle often leaves a ‘V’-shaped unit of tissue to interpose into the brow wound whilst making sure premarked brow height symmetry is retained.
11.3.6.4 Flap Delay
The rich blood supply in the forehead does permit transfer of
a ap with surgical scars, particularly if the previous surgical
intervention is known, for example, curettage, cryotherapy
or a simple skin excision of a lesion. Deep scars to the periosteum or bone may have interrupted the axiality of the ap
and design has to take this into account.
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Fig. 11.10 Large orbital exenteration, cheek resection and mid nasal
resection for basal cell carcinoma. Planned reconstruction with cheek
rotation ap and single-stage forehead with cheek extension
111
a
b
Fig. 11.11 Flap plan with cheek extension and nal ap inset. (a) ap markings with cheek extension (b) nal inset of single stage ap and cheek
rotation
112
Fig. 11.12 Cheek and nasal oor reconstruction to restore a soft tissue
platform for the nose in conjunction with rst-stage nasal reconstruction. Cartilage grafts also placed for forehead ap transfer with modied subunit completion of the nasal defect
D. B. Saleh and A. Dearden
Fig. 11.13 Cheek and nasal oor reconstruction to restore a soft tissue
platform for the nose in conjunction with rst-stage nasal reconstruction. Cartilage grafts also placed for forehead ap transfer with modied subunit completion of the nasal defect
Where there is a good Doppler signal, but scarring
(Fig.11.17), we advocate delay manoeuvres to augment the
ap prior to denitive elevation.
11.3.6.5 The Single-Stage Forehead Flap
Converse [2] popularised the islanded forehead ap for nasal
reconstruction, and the broad principles of safe harvest are
the same. We reserve this option in patients where:
1. Dual or multistage surgery is problematic.
(a) Concurrent anticoagulant therapy where there is ele-
vated risk associated with numerous episodes of
stopping and starting between stages.
Fig. 11.14 Cheek and nasal oor reconstruction to restore a soft tissue
platform prior to rst-stage nasal reconstruction in a post-Moh’s micrographic resection. V-Y advancement and full-thickness skin grafting to
the right nasal defect rim
Fig. 11.15 Cheek and nasal oor reconstruction to restore a soft tissue
platform prior to rst-stage nasal reconstruction in a post-Moh’s micrographic resection. V-Y advancement and full-thickness skin grafting to
the right nasal defect rim
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113
Fig. 11.16 Secondarily placed septal cartilage grafts with partial ap
elevation and thinning
(b) Concurrent oncological therapy.
(c) Major anaesthetic risk/interventional risks with ele-
vated frailty scores and advanced patient age.
(d) Inability for regular visits to hospital for aftercare
and repeated surgical episodes.
2. There is a mature defect where lining can be established
with ease without the need for >1cm folding of the ap—
we nd a larger requirement for lining and folding results
in potential airway impedance.
3. The patient is unwilling to have pre-expansion of the
forehead in previously scarred or very low hairline
situations.
The key difference is the need to island the ap at the
brow by only incising the skin and bluntly separating the
Fig. 11.17 A sub-total rhinectomy defect with a plan for delayed
reconstruction post-radiotherapy. A scalp reconstruction with free
anterolateral thigh ap limited the forehead donor ap. Previous BCCs
resected from right forehead including deep excision of eyebrow region.
Therefore delayed left paramedian forehead ap with division of supercial temporal vessels and vessels from the right forehead
skin and subcutaneous fat to allow rotation. Once the ap is
mobilised enough, this dissection can stop. Then the next
consideration is to split the glabellar skin or tunnel
(Figs. 11.18 and 11.19). The latter is preferable and frequently possible. Both result in glabellar prominence which
is less so in the elderly population where skin and muscle
atrophy at the radix is more common. However this is disadvantage of this technique and patients must be counselled
regarding this.
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