Arch Craniofac Surg Search


Arch Craniofac Surg > Volume 25(3); 2024 > Article
Kim and Park: Use of the frontal branch of the superficial temporal artery and the postauricular vein to overcome anatomic variations of superficial temporal vessels in scalp reconstruction with free tissue transfer: a case report


The superficial temporal artery (STA) bifurcates into frontal and parietal branches. The parietal branch is used as a recipient vessel for scalp reconstruction, but it is absent in approximately 16.3% of individuals. In this case, a 72-year-old woman with an occipital scalp defect lacked both the parietal branch of the STA and the superficial temporal vein. To address this anatomic variation, we used the frontal branch of the STA and the posterior auricular vein as alternative recipient vessels for anterolateral thigh free flap reconstruction. The surgical procedure involved end-to-end microvascular anastomosis of one artery and one vein. Partial flap necrosis occurred postoperatively, but eventually resolved with debridement. The frontal branch of the STA and the posterior auricular vein can serve as reliable alternatives in the absence of the parietal branch. Reconstructive surgeons should be aware of anatomic variations of the STA and adapt their surgical approach accordingly.



middle temporal vein


occipital artery


posterior auricular artery


posterior auricular vein


superficial temporal artery


superficial temporal vein


The superficial temporal artery (STA) courses within the superficial temporal fascia, which constitutes an extension of the galea and the superficial muscular aponeurotic system of the face, and it typically bifurcates into two branches: an anterior frontal branch and a posterior parietal branch [1]. The superficial temporal vein (STV) originates from a venous plexus on the side and vertex of the skull. It communicates with the frontal and supraorbital veins, the STV of the contralateral side, and the posterior auricular vein (PAV) and occipital vein [2].
The parietal branch of the STA and STV is more commonly used in free flap scalp reconstructions than the frontal branch, primarily due to its proximity to the wound site and the low risk of facial nerve injury. However, a study by Rusu et al. [3], which involved tomography angiograms of 43 patients, showed that the parietal branch of the STA was absent unilaterally in 16.3% of cases and bilaterally in 9.3%.
When the parietal branches of the STA and STV are absent, the occipital artery and vein may serve as alternatives. However, their distance from the wound site and the abundance of arterial branches typically render them less suitable for free tissue transfer. A deep understanding of anatomical variations and the careful selection of appropriate recipient vessels are essential for successful scalp reconstruction. This report describes a case where the absence of the parietal branch of the STA and STV necessitated the use of the frontal branch of STA and the PAV.


A 72-year-old woman arrived at the hospital with a 12×6 cm skin and soft tissue defect on her occipital scalp, caused by a traumatic head injury (Fig. 1A). Initially, she was admitted to the intensive care unit for conservative management of a subgaleal hematoma. She was then referred to the plastic surgery department for wound coverage. One week before scalp reconstruction, surgical debridement was performed to expose the periosteum. Considering the large size of the defect and the need for a long pedicle to connect the flap to the recipient artery and vein, scalp reconstruction with a free anterolateral thigh flap was planned.
A preoperative evaluation of the recipient vessel was conducted through computed tomography angiography, which revealed the absence of the parietal branch of the STA and hypotrophy of the parietal branch of the STV on the right side, which was in close proximity to the wound (Fig. 1B). Furthermore, we observed compensatory enlargement of the PAV, which coursed superiorly (Fig. 1B). However, the posterior auricular artery (PAA) and the frontal branch of the STV were relatively small for use as recipient vessels (Fig. 2A). Although the middle temporal vein was adjacent to the frontal branch of the STA, it was located beneath the superficial layer of the deep temporal fascia, making it impractical for use. Due to these anatomical variations, the decision was made to utilize the frontal branch of the STA and the PAV as alternative recipient vessels.
A preauricular skin incision was made for recipient vessel dissection, and meticulous dissection was carried out through the temporoparietal fascia and into the subcutaneous layer. The frontal branch of the STA was identified, and approximately 2–3 cm of the artery was dissected to allow sufficient length for rotation to the root of the helix (Fig. 2A). Special care was taken to avoid injury to the facial nerve during this process. Following this, a 2 cm postauricular incision was made, and the PAV was meticulously dissected to achieve a 2 cm length in the subcutaneous layer, thereby minimizing pedicle tension during the insetting procedure (Fig. 2B and C).
A 15×6 cm anterolateral thigh free flap was harvested from the left thigh. End-to-end microvascular anastomosis was performed using a 9-0 nylon suture (Fig. 3A), and adequate flap perfusion and drainage were confirmed (Fig. 3B). On the second postoperative day, venous congestion was observed at the inferior border of the flap. After removing a few stitches, improvement was noted. The patient exhibited neither facial nerve weakness nor any significant complications following the surgery (Fig. 4).


Scalp reconstruction is a complex surgical procedure that involves various techniques, including skin grafts, tissue expansion, and free tissue transfer [4-6]. Free tissue transfer is typically chosen when the defect is substantial in size and the surrounding soft tissue quality is compromised [7].
Due to their proximity, the STA and STV are generally preferred as recipient vessels [8,9]. However, alternatives such as the facial artery and vein, or the occipital artery and vein, can be considered in cases of significant size mismatch or vascular variations. Nevertheless, vein grafts pose an inherently high risk of flap failure [10].
The STA and STV typically bifurcate into frontal and parietal branches, but the absence of the parietal branches constitutes a known anatomic variation. Studies by Rusu et al. [3] and Marano et al. [11] reported this absence in 16.5% and 2% of cases, respectively. In such cases, the PAA or occipital artery, along with the PAV, takes over the vascular territory usually supplied by the parietal branch [12]. A study by Nokovitch et al. [13] reported that the common temporoparietal trunk of the STV was found in all cases, and the STV systematically preceded the STA in the preauricular area. The diameter of the STV presented major variations among individuals, with a median diameter of 1.3 mm, and the parietal branch of the STV usually had a caliber sufficient for anastomosis.
The frontal branch of the STA typically runs close to the facial nerve, which generally makes it a less favorable choice due to the risk of nerve damage. However, in our case, careful dissection allowed us to preserve the facial nerve while obtaining a sufficient length (2–3 cm) of the frontal branch for posterior rotation and anastomosis. Similarly, the PAV’s small diameter can pose challenges. Interestingly, in our case, the PAV exhibited compensatory enlargement, resulting in a diameter of 1.5 mm that was suitable for this procedure. Therefore, our case demonstrates the feasibility of utilizing the frontal branch of the STA and the PAV for scalp reconstruction, even when the parietal branches of the STA and STV are absent. To the best of our knowledge, there are few previous reports of using the PAV as the recipient vein in free flap reconstruction. Sinclair et al. [14] reported a case where the parietal branch of the STA and PAV were used at the superior aspect of the helical rim to address defects in the temporal region. However, there are no documented cases similar to ours, where the frontal branch of the STA and PAV were used for reconstructing posterior scalp defects. This highlights the novelty of our approach in addressing complex reconstructive challenges.
Preoperative angiography is crucial for reconstructive surgeons to identify anatomical variations and optimize the success of scalp reconstruction. If both parietal branches are absent, the STA frontal branch and the PAV can serve as viable alternative recipient vessels.


Conflict of interest

No potential conflict of interest relevant to this article was reported.



Ethical approval

The study was approved by the Institutional Review Board of Korea University Anam Hospital (IRB No. 2024AN0025).

Patient consent

The patient provided written informed consent for the publication and use of her images.

Author contributions

Conceptualization: Hojin Park. Writing - original draft: Dong- Jin Kim. Illustration: Dong-Jin Kim. Writing - review & editing: Hojin Park. Supervision: Hojin Park.

Fig. 1.
A 72-year-old woman presented a 12×6 cm skin and soft tissue defect on the occipital scalp resulting from a traumatic head injury with absent parietal branches of the superficial temporal artery and superficial temporal vein on her right temporal scalp. A preoperative image and computed tomography angiography show (A) a 12×6 cm occipital scalp defect and (B) absence of the parietal branch of the superficial temporal artery (black arrow), along with compensatory enlargement of posterior auricular vein (red arrow).
Fig. 2.
Recipient vessels and schematic diagram. (A) The PAV had a larger caliber than the STV and the MTV was situated beneath the superficial layer of the deep temporal fascia. (B) Posteriorly rotated frontal branch of the STA. (C) Compensatory enlargement of the PAV. STA, superficial temporal artery; STV, superficial temporal vein; PAV, posterior auricular vein; PAA, posterior auricular artery; MTV, middle temporal vein; OA, occipital artery.
Fig. 3.
Intraoperative images. (A) End-to-end anastomosis. (B) Flap insetting.
Fig. 4.
Postoperative image of recipient site 3 weeks later.


1. Jean-Philippe H, Benoit B, Francoise K, Michael D. Anatomy and external landmarks of the superficial temporal artery using 3-dimensional computed tomography. Surg Radiol Anat 2021;43:283-90.
crossref pmid pdf
2. Standring S. Gray’s anatomy: the anatomical basis of clinical practice. 41st ed. Elsevier; 2016.

3. Rusu MC, Jianu AM, Radoi PM. Anatomic variations of the superficial temporal artery. Surg Radiol Anat 2021;43:445-50.
crossref pmid pdf
4. Jang HU, Choi YW. Scalp reconstruction: a 10-year experience. Arch Craniofac Surg 2020;21:237-43.
crossref pmid pmc pdf
5. An JK, Park SO, Chang LS, Kim YH, Min K. Reconstruction of a temporal scalp defect without ipsilateral donor vessel possibilities using a local transposition flap and a latissimus dorsi free flap anastomosed to the contralateral side: a case report. Arch Craniofac Surg 2023;24:129-32.
crossref pmid pmc pdf
6. Na Y, Shin D, Choi H, Kim J, Lee M. Scalp reconstruction using the reverse temporalis muscle flap: a case report. Arch Craniofac Surg 2022;23:134-8.
crossref pmid pmc pdf
7. Park H, Min J, Oh TS, Jeong WS, Choi JW. Scalp reconstruction strategy based on the etiology of the scalp defects. J Craniofac Surg 2022;33:2450-4.
crossref pmid
8. Hansen SL, Foster RD, Dosanjh AS, Mathes SJ, Hoffman WY, Leon P. Superficial temporal artery and vein as recipient vessels for facial and scalp microsurgical reconstruction. Plast Reconstr Surg 2007;120:1879-84.
crossref pmid
9. Halvorson EG, Cordeiro PG, Disa JJ, Wallin EF, Mehrara BJ. Superficial temporal recipient vessels in microvascular orbit and scalp reconstruction of oncologic defects. J Reconstr Microsurg 2009;25:383-7.
crossref pmid
10. Song P, Pu LLQ. Microsurgical scalp reconstruction: an overview of the contemporary approach. J Reconstr Microsurg 2022;38:530-8.
crossref pmid
11. Marano SR, Fischer DW, Gaines C, Sonntag VK. Anatomical study of the superficial temporal artery. Neurosurgery 1985;16:786-90.
12. Park H, Ahn S. Vascular variation of temporoparietal fascia in microtia associated with hemifacial microsomia. J Craniomaxillofac Surg 2024;52:40-7.
13. Nokovitch L, Devauchelle B, Peyrachon B, Vacher C, Deneuve S. Anatomical characteristics of the superficial temporal venous system and implications in microsurgery. Ann Chir Plast Esthet 2021;66:250-6.

14. Sinclair S, Zhou K, Yip JM, Aggarwal S, Jukes AK, Clark JR, et al. Microsurgical scalp reconstruction and cranioplasty refined. Australas J Plast Surg 2022;5:74-9.
crossref pdf
Share :
Facebook Twitter Linked In Google+ Line it
METRICS Graph View
  • 0 Crossref
  •   Scopus
  • 287 View
  • 17 Download
Related articles in ACFS


Browse all articles >

Editorial Office
Dept. of Plastic and Reconstructive Surgery Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
Tel: +82-62-220-6354    Fax: +82-62-220-6357    E-mail:                

Copyright © 2024 by Korean Cleft Palate-Craniofacial Association.

Developed in M2PI

Close layer
prev next