Vessels for Facial and Scalp.pdf

RECONSTRUCTIVE Superficial Temporal Artery and Vein as 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 adequ
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  RECONSTRUCTIVE Superficial Temporal Artery and Vein asRecipient Vessels for Facial and ScalpMicrosurgical 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:  Althoughfreeflaptransferiscommonlyperformedtoreconstruct defects of the upper two-thirds of the face and scalp, the superficial temporalarteryandveinhavehistoricallynotbeenconsideredadequateformicrosurgicalreconstruction and have rarely been described as recipient vessels. The purposeof this study was to determine the indications for and effectiveness of using thesuperficial temporal vessels for scalp and face reconstruction. Methods:  Retrospective chart review on all patients undergoing microsurgicalreconstruction for defects of the upper two-thirds of the face between 1996 and2003revealed45freetissuetransfersinwhichthesuperficialtemporalarteryand 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 superficialtemporal artery was used as the recipient artery in every case. In three cases, thesuperficial temporal vein was not suitable as the recipient vein and required useof 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 samesuperficial temporal artery and vein as recipient vessels. Conclusions:  Use of the superficial temporal artery and vein for scalp and facereconstruction is reliable and safe. The superficial temporal artery and veinshould be considered as primary recipient vessels in microsurgical reconstruc-tionoftheuppertwo-thirdsofthefaceand/orscalp. ( 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 hasshifted to optimizing this process. Experience hastaught us that only a select number of donor sitesare needed for the majority of reconstructions.For the upper two-thirds of the face and scalp, therectus abdominis and latissimus dorsi muscles,andlesscommonlythescapularflap,providegreat flap reliability and flexibility in restoring the nor-mal soft-tissue contour to the scalp and midface while obliterating the maxillary and/or orbitalcavities when desired (Fig. 1). When thin resur-facing of the scalp is indicated, the radial forearmflap has been an ideal choice. 1–3 Incontrasttodonor-siteselection,theoptimalchoice of recipient vessels for scalp and midfacialreconstruction is less well defined. When Schus-terman et al. reviewed their experience with 308microsurgical reconstructions, they documentedthat greater than 90 percent of their recipient  vesselswerelarge-calibervesselsintheneck. 4 They felt that using large-caliber vessels enhanced theirsuccess rate. Subsequent studies by members of thereconstructiveteamfromtheMemorialSloan-Kettering Cancer Center have endorsed the needto use recipient vessels in the neck. 2,3,5 The rec-  From the Division of Plastic and Reconstructive Surgery,University of California, San Francisco.ReceivedforpublicationFebruary6,2006;acceptedJune15,2006.Presented at the American Society for Reconstructive Micro- surgery meeting, in Palm Springs, California, January 15 through 18, 2005.Copyright©2007bytheAmericanSocietyofPlasticSurgeons  DOI: 10.1097/ 1879  ommended recipient vessels for flaps commonly included the facial, lingual, external carotid, su-perior thyroid, and superficial cervical arteriesand their corresponding venous systems. How-ever, Cordeiro et al. also acknowledged that thelong distance from the midface to the neck was achallenging aspect of free flap reconstruction. 3 Despite techniques to increase pedicle length, veingraftingmaybenecessarytospanthe10to12cm to the ipsilateral neck. 3  With all that has been written about head re-construction for defects of the upper two-thirds of theface,littlehasbeenwrittenconcerningtheuseof the superficial temporal artery and vein as re-cipient vessels. Hussussian and Reece used thesuperficial temporal vessels in less than one-thirdof 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-constructionsandadvocatedtheiruse. 7 Moreover,a recent study reported using the temporal vesselsin approximately 20 percent of their head andneck reconstructions. 8 Todate,nocenterhasevaluatedalargegroupof patients undergoing microvascular free tissuetransfer to the superficial temporal vessels. Thepurpose of this study was to determine the indi-cations for and the effectiveness of using the su-perficial temporal vessels for microvascular faceandscalpreconstruction.Inaddition,wedocument techniques to optimize the use of these vessels. PATIENTS AND METHODS  Aretrospectivechartreviewwasperformedonall patients with defects of the scalp and uppertwo-thirds of the face who underwent microsurgi-cal reconstruction with free flap transfer between January of 1996 and December of 2003 at theUniversity of California, San Francisco and affili-ated hospitals. From that group of patients, thosecases in which the superficial temporal artery and vein were used as recipient vessels were furtheranalyzed and form the basis for this study. Appro-priate University of California, San FranciscoCommittee 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 superficialtemporal vessels were attempted in 43 patientsafter they were evaluated preoperatively to have apalpable superficial temporal artery. Seventy-oneof 257 patients that underwent microsurgical re-construction had defects in the scalp/midface re-gion. Of these 71 patients, 12 had defects in theparotid or ear region and thus the superficial tem- Fig.1.  ( Left  )Preoperativeviewofamanwithaposteriorscalpdefectdemonstratestheextentofthedefectafter a failed local flap. ( Right  ) Postoperative view several months after successful latissimus dorsi flap andskin grafting. Plastic and Reconstructive Surgery  ã  December 2007 1880  poral vessels were not suitable for microsurgicalreconstruction purposes. The superficial tempo-ral artery and vein were not used in 14 of 59patientswhohaddefectsintheorbit/midfaceandtheir flap was better positioned if the vessels in theneck 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.Theagesofthepatientsrangedfrom2to91years, with a median age of 63 years. The areas of re-construction included scalp ( n   19), orbit ( n   4),skullbase( n   4),midface( n   4),andorbitaland midface ( n     14) defects. The tissue trans-ferred included the rectus abdominis ( n     23),radialforearm( n   9),latissimus( n   8),scapularflap ( n   4), and serratus ( n   1) and was basedon the size and contour of the defect (Table 1).The volume of our defects ranged from 32 cm 3 to500cm 3 ,withameandefectsizeof129cm 3 .Twenty-eight of the patients (65 percent) had undergoneprevious radiation therapy. All anastomoses wereperformed in an end-to-end fashion using inter-rupted 9-0 nylon suture. Bony replacement wasnot necessary for any of the reconstructions. Be-ginning in 2000, the majority of our patients hadan implantable Doppler device placed around therecipientveindistaltothevenousanastomosisthat provided continuous flap monitoring for 5 to 7dayspostoperatively.Neitherdextrannorheparin was routinely administered postoperatively. Only patients who required take-back for anastomoticcomplications 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.Therewasminimalatherosclerosisnotedinthe superficial temporal artery for all patients. In40 of the patients, we were able to identify themain trunk of the superficial temporal vein, andit 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.Threeofthe43patientshadagreaterthan2:1discrepancy between the donor vein and the su-perficial temporal vein on initial exploration. Inthesethreepatients,anipsilateralexternaljugular vein, ipsilateral retromandibular vein, or con-tralateral facial vein was used; the latter two re-quired interposition vein grafts. The overall flapsurvival rate was 96 percent. The overall compli-cation rate was 31 percent (Table 2). Five patients(11 percent) required a return to the operatingroom for vascular compromise. All flaps requiring vascular revision were taken back to the operatingroom within 24 hours. Two of these patients weremonitored with an implantable Doppler deviceand were returned to the operating room within2 hours of identifying a change in the Dopplersignal. Two of the five patients were noted to havean arterial thrombosis, and their anastomosis wasrevised. The other three patients experienced a venous thrombosis at the anastomotic site. Of thesethreepatients,onerequiredarevisionoftheanastomosis.Asecondpatienthadthevenousout-flow revised with an interposition vein graft to thefacial 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 venacomitans of the superficial temporal artery. There were no anatomical problems noted in the recip-ient veins in the three patients who experiencedavenousthrombosis.Moreover,wedidnotseeany correlation between venous thrombosis and pres-ence of a suitable superficial temporal vein. Thethree patients who had venous thrombosis were Table2. Complications(n  14) Complications No.  Venous thrombosis 3 Arterial thrombosis 2Hematoma* 5Late flap loss† 1Cellulitis‡ 1Necrosis 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. Table1. ChoiceofFlapbySiteofReconstructionin43Patients Site of Reconstruction No. of Flaps Scalp (n  19)Latissimus 8Radial forearm 5Rectus 3Scapular 3Orbit and midface (n  14)Rectus 13Scapular 1Orbit only (n  4)Rectus 4Midface only (n  4)Rectus 1Serratus 1Radial forearm 2Skull base (n  4)Rectus 2Radial forearm 2  Volume 120, Number 7  ã  Temporal Vessels for Reconstruction 1881  differentfromthethreepatientswhodidnothavesufficiently large superficial temporal veins andrequired the use of veins in the neck. The secondpatient with flap loss initially had arterial throm-bosisthatrequiredrevisionoftheanastomosisandthe 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.Thelengthoffollow-uprangedfrom3monthsto 8 years, with an average of 4 years. Two flaps (4percent) in this series failed. One was a patient thatinitiallyrequiredtake-backforarterialthrom-bosis resulting from arterial kinking. After thistake-back, the patient was started on heparin anddeveloped a hematoma under the flap. This flapsubsequently failed and the patient underwent re-construction with another flap performed to thesame superficial temporal vessels without furtheradversesequelae.Asecondpatientdevelopedflapfailure during the perioperative period despitebeing discharged to home with a viable flap. Fur-ther evaluation determined that the patient usedher 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 hassignificantly improved the quality of life for many patients. Refining donor-site selection has furtherimproved results. 1–3,5–7 For the upper two-thirds of theface,whereboneflapsarerarelynecessary,theradial forearm, rectus abdominis, and latissimusdorsi flaps are our flaps of choice. For coverage of large wounds, the rectus abdominis and latissimusdorsi musculocutaneous flaps are preferred.These flaps are effective in skull base coverage,particularly after a dural resection and repair wheremusclebulkisimportanttoadequatelypro-tect the repair. The thin, broad muscle of thelatissimusflap(incombinationwithskingrafting)isespeciallywellsuitedafterlargescalpresections. 7 Forsmall defects, the radial forearm fasciocutaneousflapprovidesthin,pliableskinwithlimitedsoft-tissuebulk, characteristics that make it ideal for resurfac-ing the cheek and scalp.Historically, concerns about vessel diameterand supplying enough blood to support flaps witha large surface area have limited the use of thesuperficial temporal vessels for head and neck re-construction. In contrast to previous reports, ourseries suggests that virtually all flap reconstruc-tions to the scalp and midface can be successfulusing the superficial temporal vessels no matter which flap is used. Anatomical studies in the lit-erature examining vessel diameters in the headand neck suggest that the difference in vessel di-ameters of the superficial temporal and facial ar-teryandveinmaynotbeassignificant,onaverage,as has been understood. 9,10  We have found the anatomical course of thesuperficial temporal vessels to be very reliable andconsistent 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 overthe root of the zygomatic process of the temporalbone. It consistently divides into two majorbranches: the frontal and parietal branches. 9,11 Therecipientarterialanastomosisinourstudywasalways at the main trunk of the superficial tem-poral artery, anterior to the tragus, before thebranch point (Fig. 2). The spectrum of size dis-crepancies between recipient and donor vesselsranged 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 inone patient whose flap failed after initial difficul-ties with the arterial anastomosis, in the subse-quent free flap reconstruction.The superficial temporal vein demonstratesmore variability with respect to its branching pat- Fig.2.  Intraoperativedemonstrationofthesuperficialtemporalartery and vein dissected just anterior to the tragus. Plastic and Reconstructive Surgery  ã  December 2007 1882


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