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Genigraphics Research Poster Template 44X30 Harvesting the Middle Temporal Artery for Bypass: Microanatomical Description and Surgical Technique Roberto Rodriguez Rubio, MD1,2; Halima Tabani, MD1,2; Michael T Lawton, MD1,2; Sonia Yousef BS1,2; Olivia Kola1,2; Arnau Benet, MD1,2 1Department of Neurological Surgery, University of California, San Francisco 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco Objective Discussion To present a novel isolation technique of the MTA using a conventional This is the first microanatomical and morphometric study of the curvilinear incision for an anterolateral approach, and to evaluate its neurosurgical exposure of the MTA. Although previous clinical studies morphological characteristics with the aim of using it in cerebrovascular have demonstrated the use of an MTA-based flap for reconstruction of bypass surgery. the surgical cavity post-mastoidectomy2 and in otological procedures,3 there is no common nomenclature for its branches or anatomical landmarks related to its particular orientation. Background The potential of MTA as a donor for cerebral revascularization has not The middle temporal artery (MTA) is the proximal medial branch of the been explored. The medial disposition and relatively hidden position superficial temporal artery (STA). MTA supplies the temporalis muscle between the temporalis muscle and fascia could lead to unnoticed along with the deep temporal arteries. Its use in vascularized flaps for damage during temporalis muscle dissection and/or reflection during reconstructive and otological procedures have been described, yet its standard anterolateral neurosurgical approaches. However, we found potential use in neurosurgery is not studied. We report a novel technique that the MTA was easy to locate and unlikely to be damaged for exposing the MTA and evaluated its characteristics for a extracranial- inadvertently during anterolateral approaches, if one keeps its location intracranial (EC-IC) cerebrovascular bypass. and trajectory in mind while isolating and harvesting it from the temporalis muscle (Figure 2). Our results reveal that the MTA offers a caliber that is at par with other, Methods and Materials more commonly used, donors for EC-IC low flow bypass. The proximal Ten specimens were prepared using our laboratory’s embalming portion of MTA has a caliber of 1.7 ± 0.4 mm, similar to STA at the level protocol.1 Each specimen was positioned in a 3-pin head clamp with a of bifurcation (1.7 ± 0.5 mm).4 The distal portion of MTA offers a caliber 20 degree rotation contralateral to the side of approach an with a 20 of 1.3 ± 0.5 mm, similar to the frontal branch (1.3 to 2.1 mm) and parietal degree extension. A curvilinear skin insicion was performed beginning at branch (1.2 to 1.8 mm) of STA directly after the bifurcation.4-8 the zygomatic arch and ending at midline, slightly behind the hair line. The STA was identified and dissected from distal to proximal, and the The evidence provided in this study suggests that there is a potential use horizontal portion of the MTA was located posterolateral to the posterior for the MTA either as an interposition graft or for direct anastomosis, edge of the zygomatic root (PEZR) and it was followed proximally until its however we did not sought to define the latter. In cases of accidental origin, and distally until the visualization of two terminal branches iatrogenic distal STA damage9 or previous anastomosis of distal (anterior, and posterior). The total length, visible branches, and calibers branches,10 the MTA could potentially offer an alternative option for of MTA were recorded. cerebral revascularization. Conclusions We report a novel surgical technique to expose the MTA efficiently using a standard anterolateral approach, which allows for its potential application in cerebral revascularization surgery. The topography and morphometric characteristics of MTA justify its use as an alternative vessel for EC-IC bypasses in very well selected cases, and where other options (e.g. distal STA) are not available. However, the role of the MTA as either direct donor or interposition graft in cerebral revascularization will require specific and thorough studies on each possible bypass combination. A B Figure 1. Anterolateral view of a macroscopic dissection of the superficial temporal artery (STA) and its branches. AAA= Anterior auricular artery; MTA= Middle temporal artery; STA= Superficial temporal artery. Results The total mean length of the harvested MTA was 31.7±5.1 mm, with a proximal mean caliber of 1.7±0.4 mm, and a distal mean caliber of 1.3±0.5 mm. Four to six terminal branches (4.9 ± 0.9) were found during C D our dissection of the MTA (Figure 1). These branches were: a small medial parotideal branch (7/10), an anterior fascial branch (10/10), an anterior muscular branch (3/10), a posterior muscular branch (10/10), and two distal branches (10/10) (i.e. anterior and posterior). The caliber of the proximal STA trunk was 2.5±0.5 mm. The origin of the MTA was visible with a mean distance of 16.9 ±4.9 mm inferior to the PEZR. The parotid gland was partially traversed and a communicating auriculotemporal nerve to the temporal branch of the facial nerve crossed the MTA in 2 specimens. Figure 2. Stepwise exposure of the middle temporal artery (MTA). A. Identification of the superficial temporal artery (STA) and the MTA posterolateral to the posterior edge of the zygomatic root (PEZR). B. After reflecting the temporalis muscle (TM), the muscular branch (mMTA) of the MTA is dissected distally. C. The MTA is cut distally at its posterior bifurcation and prepared to be used as a donor. D. Extracranial- Intracranial bypass of MTA to M4 (middle temporal artery). fSTA= Frontal branch of STA; fMTA= Fascial branch of MTA; pSTA= parietal branch of STA; SQS= Squamous suture. Contact References 1. Benet A, Rincon-Torroella J, Lawton MT, Gonzalez Sanchez JJ. Novel embalming solution for neurosurgical simulation in cadavers. J Neurosurg. May Roberto Rodriguez Rubio 2014;120(5):1229-1237. 2. Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg. Jan Department of Neurological Surgery, University of California, San Francisco 1986;77(1):17-28 3. Fagan PA, Rodrigues SJ. Middle temporal artery flap in mastoid surgery. Otol Neurotol. May 2004;25(3):242-244. Skull Base and Cerebrovascular Laboratory, University of California, San Francisco 4. Medved F, Manoli T, Medesan R, et al. In vivo analysis of the vascular pattern of the superficial temporal artery based on digital subtraction angiography. Microsurgery. Jul 2015;35(5):380-386. Email: [email protected] 5. Pinar YA, Govsa F. Anatomy of the superficial temporal artery and its branches: its importance for surgery. Surg Radiol Anat. Jun 2006;28(3):248-253. 6. Marano SR, Fischer DW, Gaines C, Sonntag VK. Anatomical study of the superficial temporal artery. Neurosurgery. Jun 1985;16(6):786-790. Website: skullbaselab.ucsf.edu 7. Stock AL, Collins HP, Davidson TM. Anatomy of the superficial temporal artery. Head Neck Surg. Jul-Aug 1980;2(6):466-469. 8. Chen TH, Chen CH, Shyu JF, Wu CW, Lui WY, Liu JC. Distribution of the superficial temporal artery in the Chinese adult. Plast Reconstr Surg. Oct 1999;104(5):1276-1279. 9. Jang IS, Ahn JS, Kwon DH, Kwun BD, Lee JK. Salvage techniques for STA-MCA bypass. Br J Neurosurg. Apr 2010;24(2):202-204. 10. Germans MR, Regli L. Posterior auricular artery as an alternative donor vessel for extracranial-intracranial bypass surgery. Acta Neurochir (Wien). Nov 2014;156(11):2095-2101; discussion 2101. .
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