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A Cadaver Study ORIGINAL ARTICLE The Vascular Anatomy and Angiosome of the Posterior Auricular Artery A Cadaver Study LCDR Brian J. McKinnon, MC, USN; CDR Maryann P. Wall, MC, USN; CDR Daniel W. Karakla, MC, USN Background: Pedicled flaps based on the posterior au- able course in the posterior auricular sulcus. The branch- ricular artery have been used for small auricular and mas- ing pattern over the auricle and temporal bone and the toid cavity defects. artery’s relationship to bony and soft tissue landmarks were consistent. The angiosome includes the anterior and Objective: To precisely define the vascular anatomy and posterior surfaces of the auricle and the periauricular skin angiosome (cutaneous distribution) of the posterior au- superiorly, posteriorly, and inferiorly. ricular artery. Conclusions: The investigation documented the consis- Methods: A fresh cadaver model was used for 3 separate tent vascular anatomy and angiosome of the posterior au- investigations, studying the posterior auricular artery. Intra- ricular artery. The cutaneous distribution suggests that a arterial ink injections defined the angiosome, and subtrac- large pedicled or island flap based on the posterior auricu- tion angiography and latex injection defined the vascular lar artery may be raised safely as a myocutaneous or myo- anatomy in relation to bony and soft tissue landmarks. fasciocutaneous flap with temporalis fascia and/or perios- teum, extending previously published dimensions. Further Subjects: Eight fresh cadavers, 6 men and 2 women, were studies may extend the clinical application to include free used, varying in age from 58 to 85 years. flaps based on the posterior auricular artery. Results: The posterior auricular artery has a predict- Arch Facial Plast Surg. 1999;1:101-104 HE POSTERIOR auricular ar- this area was consistent. The anterior ex- tery (PAA) is a small branch tent of the blush included the lobule and oftheexternalcarotidartery. the middle and superior portions of the The artery leaves the exter- pinna posterior to the meatus of the exter- nal carotid just superior to nal canal as seen in a representative sample Tthe occipital artery and courses anterior to in Figure 1. The mean distance from the the mastoid tip and posterior to the pinna. mastoid to the tragus was 3.92 cm. Mea- It supplies the majority of the skin of the suring from the superior portion of the tra- auricle as well as the postauricular skin. gus, the mean distance to the superior, pos- Myocutaneous flaps based on the PAA have terior, and inferior borders of the ink blush been used for auricular reconstruction1-4 be- (angiosome) were 6.88 cm, 5.31 cm, and cause of its good color and texture match 7.59 cm, respectively. Measuring from the and its accessible location. Myofascial flaps mastoid tip, the mean distance to the su- based on the PAA have been used for mas- perior, posterior, and inferior borders of the toid obliteration.5 ink blush (angiosome) were 9.99 cm, 6.68 In an effort to extend the clinical ap- cm, and 3.99 cm, respectively. plications of pedicled myocutaneous flaps Latex injections of the PAA are re- to explore the feasibility of free myocutane- corded in Table 2. The measurements for ous flaps based on the PAA, this study was location of the latex-injected PAA were conducted to investigate the anatomy and taken from the external carotid artery, mas- angiosome of the PAA. toid tip, external auditory canal, and the su- perior attachment of the helix (Figures 2 From the Naval Medical RESULTS and 3). The PAA had a mean distance of Center, Portsmouth, 0.29 cm anterior to the mastoid, just deep Otolaryngology–Head and The measurements of the 14 PAA ink in- to the lobule and in the posterior auricu- Neck Surgery, Portsmouth, Va. jections are shown in Table 1. Staining of lar sulcus. Measuring parallel to the Frank- ARCH FACIAL PLAST SURG/ VOL 1, APR-JUNE 1999 101 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 MATERIALS AND METHODS 10 mL of intra-arterial radiographic contrast hand-injected into the artery, with a second film exposed immediately on completion. The mask radiograph was subtracted from the A fresh cadaver model was used for 3 separate investiga- injection radiograph to produce the final radiograph tions studying the PAA. A total of 8 cadavers were used, 6 (Figure 2). men and 2 women, with an age range of 58 to 85 years (average age, 74 years). Through an incision 2 cm below LATEX INJECTION the angle of the mandible, the branches of the external carotid were identified. The PAA was cannulated with a A total of 15 PAAs were hand-injected with red or blue la- 20-gauge catheter. The remaining branches were suture tex (Batson #17 Plastic Kit; Polysciences Inc, Warrington, ligated. Pa). After the latex had been allowed to set overnight at 4°C, the skin at the perimeter of the most posterior ink blush INK INJECTION was incised. As the dissection extended through the sub- dermal layer, the latex-filled perforators were traced to the Fourteen PAAs underwent intra-arterial ink injections to junction of the PAA and external carotid artery. As the per- define the angiosome, using the method described by forating vessels were identified, they were followed through Whetzel and Mathes.6 Commercially available fountain the temporoparietal fascia. The PAA proceeded from the pen ink was used to determine the cutaneous area sup- external carotid artery, then anterior to the mastoid tip, and plied by the PAAs. Ink was gently hand-injected through deep to the posterior auricular muscle (Figure 3). Mea- the catheter until the resulting cutaneous blush did not surements of its course were obtained from bony and soft increase in size, approximately 10 mL in each case. The tissue landmarks. area of cutaneous ink blush was measured and photo- graphed (Figure 1). STATISTICAL ANALYSIS RADIOGRAPHIC EXAMINATION All measurements were entered into and statistical opera- tions performed using a Microsoft Excel for Windows 95 Sixteen PAAs underwent subtraction angiography using intra- worksheet (Microsoft Corp, Redmond, Wash). A 95% con- arterial radiographic contrast. Best results were achieved us- fidence interval (CI) was calculated to allow us to be 95% ing a grid with the source set at 40 cm from the film with confident that the true population mean would be in- exposure settings of 70 kV and 10 mA/s . The cadaver was cluded in our interval, which was constructed around our positioned and a mask film was exposed, followed by mean sample. Superior Superior Tragus A D Posterior B C E Posterior F Inferior Mastoid Tip Average Distance, cm A 6.9 D 10.0 B 5.3 E 6.7 C 7.6 F 4.0 Figure 1. A, An example of the posterior auricular artery angiosome documented following ink injection. B, The landmarks used to document the size of the ink-stained area. fort plane from the center of the external auditory canal, to penetrating the temporoparietal fascia measured from the PAA was a mean distance of 1.19 cm posterior to the the mastoid tip was 7.56 cm. In 11 (65%) of 17 dissec- external auditory canal and in a plane drawn from the su- tions, the artery had penetrated the temporoparietal fas- perior orbital rim through the superior attachment of the cia below the level of the superior helical attachment. helix to the scalp a mean distance of 2.38 cm posterior to Branches of the PAA were documented. The 2 the helical attachment. The mean length of the artery prior branches identified most consistently were the auricu- ARCH FACIAL PLAST SURG/ VOL 1, APR-JUNE 1999 102 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 STA STA PAA PAA External Auditory Canal Mastoid Tip STA PAA Figure 2. A, An example of plain angiography. B, The use of subtraction angiography documented the remarkable anastomotic network between the ipsilateral superficial temporal artery (STA), anterior auricular and occipital arteries, and the contralateral cutaneous vascular territories. PAA indicates posterior auricular artery. Occipital Branch PAA D C B Auricular A Branch PAA Figure 3. A, An example of the latex-injected posterior auricular artery (PAA), the course of the vessel and location of PAA branches. B, The landmarks used for documenting the location of the latex-injected PAA. Line A marks the distance of the PAA anterior to the mastoid tip, and line B marks the length of the PAA superior to the mastoid tip. The posterior course was measured from the center of the external auditory canal as it passed through the Frankfort plane (line C), and posterior to the helical attachment in a plane drawn from the superior orbital rim through the superior attachment of the helix to the scalp (line D). lar branch to the posterior portion of the pinna (11 [65%] had multiple branches, and 5 dissections had sternoclei- of 17 latex injections) and the occipital branch (11 [65%] domastoid branches. Measured from the external ca- of 17 dissections). Both the occipital and the pinna rotid artery, the parotid branch was located at 1.75 cm, branches had their takeoff at or superior to the mastoid and the sternocleidomastoid branch was located at 1.44 tip. The occipital branch mean distance was 0.84 cm above cm. No cervical branches were identified, which could the mastoid tip, and the auricular branch mean distance have been the result of placement of the catheter in the was 0.68 cm above the mastoid tip. Below the mastoid artery or a ligature at the insertion site that blocked the tip, 6 dissections showed a parotid branch, one of which latex from filling the branch.
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