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Superficial temporal artery

The superficial temporal artery (STA) is a terminal branch of the external carotid artery, originating within the parotid gland at the level of the neck of the mandible and ascending to supply oxygenated blood to the scalp, face, and associated structures. It emerges posterior to the mandible, courses anterior to the external ear and over the zygomatic arch, and typically bifurcates into frontal and parietal branches approximately 3–5 cm above the arch, providing a palpable pulse in the temporal region.^[1]^[2] In its course, the STA travels tortuously through the superficial temporal fascia, initially deep to the parotid gland before becoming superficial, and divides into its terminal branches within the temporal fossa to irrigate the frontal scalp, parietal region, temporalis muscle, and parts of the face including the orbicularis oculi and masseter muscles. Key branches include the transverse facial artery (supplying the parotid region and masseter), zygomatico-orbital artery (to the orbicularis oculi), middle temporal artery (to the temporalis muscle), anterior auricular branches (to the external ear), and the aforementioned frontal and parietal terminals, with occasional variations such as trifurcation or ethnic-specific bifurcation patterns (e.g., higher arch-level splits in Caucasians).^[3]^[2]^[4] Clinically, the STA holds significance in vascular surgery, serving as a conduit for cerebral revascularization in procedures like superficial temporal artery-middle cerebral artery bypass for conditions such as moyamoya disease, and it is also utilized in endovascular diagnostics and treatments due to its accessibility. It is implicated in pathologies including temporal arteritis (giant cell arteritis), which causes inflammation leading to headaches and vision disturbances, as well as rare complications like pseudoaneurysms or emboli during facial aesthetic procedures such as fillers or fat grafting near the zygomatic arch.^[1]^[4]^[2]

Anatomy

Origin and course

The superficial temporal artery arises as the smaller terminal branch of the external carotid artery within the parotid gland, at the level of the neck of the mandible, approximately corresponding to the level of the external auditory meatus.^[5]^[2]^[1] From its origin, the artery ascends anterior to the external auditory meatus and tragus, passing between the temporomandibular joint and the cartilage of the external ear, while traversing the posterior portion of the parotid gland beneath the facial nerve.^[5]^[2] It then crosses the posterior aspect of the zygomatic arch, specifically over the zygomatic process of the temporal bone.^[5]^[2] The artery continues its superior trajectory within the temporoparietal fascia, superficial to the temporalis muscle, and becomes subcutaneous as it enters the temporal region of the scalp.^[5]^[2] In the temporal region, the superficial temporal artery typically bifurcates into frontal and parietal branches approximately 3 to 5 cm above the zygomatic arch.^[6]^[7] From its origin to this bifurcation point, the artery measures about 6 to 8 cm in length, with an initial diameter of roughly 2 to 3 mm that tapers distally along its course.^[7]^[8]

Branches

The superficial temporal artery gives rise to multiple branches that supply various structures in the face, scalp, and temporal region, with the terminal branches being the most prominent. These branches typically originate along its course from the parotid gland superiorly toward the temporal fossa, exhibiting some anatomical variability in their points of origin and paths.^[9] The transverse facial artery arises near the origin of the superficial temporal artery within the parotid gland and courses anteriorly, parallel to the zygomatic arch, over the masseter muscle to supply the parotid gland, parotid duct, masseter muscle, and adjacent facial skin.^[2]^[3] The anterior auricular artery originates early in the course of the superficial temporal artery, often near the superior root of the helix, and ascends posteriorly to supply the auricle, external acoustic meatus, and surrounding skin of the external ear.^[9]^[2] The zygomatico-orbital artery branches off superior to the zygomatic arch and penetrates the temporalis muscle, directing small vessels to supply the orbicularis oculi muscle, temporal region, and zygomatic area.^[2]^[3] The middle temporal artery emerges near the zygomatic arch or close to the bifurcation of the main artery and runs posteriorly over the temporal fascia to supply the temporalis muscle and adjacent pericranium.^[9]^[2] The frontal branch, also known as the anterior temporal branch, is the larger of the two terminal branches and arises from the bifurcation in the temporal fossa; it ascends tortuously anterosuperiorly over the forehead toward the vertex, supplying the frontal scalp, pericranium, and lateral forehead muscles while anastomosing with the supraorbital and supratrochlear arteries.^[9]^[3] The parietal branch, or posterior temporal branch, is the smaller terminal branch emerging at the same bifurcation; it curves superiorly and posteriorly over the scalp to reach the occipital region, providing blood to the parietal scalp and pericranium while connecting with the occipital artery.^[9]^[2] In addition to these major branches, the superficial temporal artery emits minor auricular and parotid branches within the parotid gland, which supply local glandular tissue and small auricular structures.^[2]

Relations

In the parotid region, the superficial temporal artery arises as a terminal branch of the external carotid artery within the substance of the parotid gland, lying deep to the parotid fascia that encapsulates the gland.^[10] It is positioned lateral to the external carotid artery and the retromandibular vein, which forms from the union of the superficial temporal and maxillary veins in this area.^[10] The artery passes superficial to the branches of the facial nerve, which divide the parotid into superficial and deep lobes.^[9] At the zygomatic arch, the superficial temporal artery crosses superficially over the arch and the zygomatic process of the temporal bone, located anterior to the temporomandibular joint capsule.^[3] The auriculotemporal nerve accompanies the artery here, crossing it posteriorly as it ascends toward the temple.^[11] In the temporal region, the superficial temporal artery lies superficial to the temporalis muscle and the deep temporal fascia that invests it.^[12] It courses within the temporoparietal fascia, which is continuous inferiorly with the superficial musculoaponeurotic system (SMAS), and is covered superficially by subcutaneous tissue.^[12] The artery is positioned lateral to the superficial temporal vein, which typically runs on its superficial or lateral aspect within or above the temporoparietal fascia.^[13] At its bifurcation in the temporal region, approximately 3–5 cm above the zygomatic arch, the frontal branch of the superficial temporal artery relates closely to the frontalis muscle, anastomosing within its substance, while the parietal branch associates with the occipitalis muscle as part of the occipitofrontalis complex.^[4] Both terminal branches lie deep to the galea aponeurotica, the fibrous sheet connecting the frontal and occipital bellies.^[12] Throughout much of its course, the superficial temporal artery is accompanied by the auriculotemporal nerve, providing sensory innervation to the overlying scalp, and by superficial temporal lymph nodes that drain the lateral scalp and temple regions.^[2]^[14]

Variations

Anatomical variations

The superficial temporal artery (STA) typically originates as one of the two terminal branches of the external carotid artery within the parotid gland, but variations in its origin include an earlier bifurcation at the cervical level, as documented in cadaveric dissections where the STA divided near the posterior belly of the digastric muscle, approximately 4 cm below the external auditory canal.^[15] Such early origins are rare and may involve compensatory adjustments in adjacent vessels like the posterior auricular artery.^[15] Branching patterns of the STA show considerable variability, often classified into types based on the number and configuration of terminal branches. According to Medved et al., five main types (A-E) encompass 11 subtypes, ranging from the classic bifurcation into frontal and parietal branches (prevalent in 11.4-80.2% of cases) to trifurcations (6.7%) or double frontal/parietal branches (1.4-40%).^[4] Lee et al. described Type I as the most common (96.9%), featuring a single or double frontal branch, while Type II includes more complex duplications.^[4] Atypical patterns, such as absence of the parietal branch (unilateral in 16.3%, bilateral in 9.3%) or frontal branch (approximately 4.7% unilateral), occur in up to 20% of individuals, with atrophic or hypoplastic branches reported in 8-76% depending on the study population and imaging modality.^[16] Cadaveric and angiographic studies indicate overall branching variations in 15-40% of cases, influenced by ethnic differences, such as higher rates of double branches in African populations.^[4] Course anomalies of the STA are less frequent but include tortuosity or kinking, observed in 88.4% of vessels in computed tomography angiography analyses, often at the zygomatic arch (81.4%) or posterior zygomatic root (27.9-32.6%).^[16] Duplication of the main trunk is exceedingly rare, while hypoplastic courses are uncommon, typically involving reduced caliber without complete absence.^[4] These deviations stem from embryological development, as the STA derives from the third aortic arch via the external carotid system.^[17] Overall, anatomical variations occur with significant frequency based on combined cadaveric and radiographic data, underscoring the need for preoperative imaging in vascular procedures.^[4]

Clinical implications of variations

Anatomical variations in the superficial temporal artery (STA) can complicate biopsies for temporal arteritis. In cases of giant cell arteritis, the standard biopsy targets the frontal branch, but variations like absent branches may affect identification.^[16] Variations in the STA's origin or course pose significant challenges in surgical planning, particularly for superficial temporal artery to middle cerebral artery (STA-MCA) bypass procedures used in cerebrovascular ischemia. Hypoplastic or absent parietal branches, reported in up to 16% of cases, may render the artery unsuitable as a donor vessel, necessitating alternative approaches and preoperative assessment.^[16] Doppler ultrasound or computed tomography angiography (CTA) is essential to detect such anomalies, as retrocondylar origins or kinking—present in 88.4% of STAs—can alter the surgical trajectory and increase operative risks.^[16] In aesthetic procedures, unexpected STA positions heighten the risk of vascular complications, including occlusion and embolism during dermal filler or fat grafting injections in the temporal region. Reported cases include pseudoaneurysms and cerebral infarctions following rhytidectomy or filler administration, with danger zones identified 47 mm superior to the supraorbital rim where variations amplify injury potential.^[4] These risks underscore the need for precise anatomical mapping to avoid iatrogenic vascular events. Diagnostic imaging can be confounded by STA variations, where absent or duplicated branches may simulate occlusive disease on angiography, leading to misinterpretation in conditions like Moyamoya disease or arteritis.^[18] Ethnic differences in bifurcation patterns further complicate assessments, with a greater percentage of arteries bifurcating on the level of the zygomatic arch among the Caucasian population compared to African and Asian ethnicities.^[4] To mitigate these implications, routine screening for STA variations using CTA or ultrasound is recommended prior to high-risk surgeries, such as bypass or reconstructive flaps, to ensure procedural safety and efficacy.^[15] This approach allows for tailored interventions, reducing complication rates in variant cases.^[4]

Function

Areas supplied

The superficial temporal artery (STA) primarily vascularizes superficial structures of the lateral face, temple, and superior scalp through its branches, contributing to the nourishment of skin, muscles, and glands in these regions.^[4] Parotid branches arising from the proximal trunk of the STA supply the parotid gland and its capsule, ensuring adequate perfusion for this salivary structure as the artery emerges within the gland posterior to the mandible.^[19] The transverse facial branch of the STA, which arises within the parotid gland, provides blood to the masseter muscle, parotid fascia, and adjacent facial tissues, supporting the lateral cheek and masticatory apparatus.^[19] The frontal branch extends superiorly to vascularize the skin of the forehead and the frontalis muscle, while the parietal branch supplies the temporal and parietal regions of the scalp, including overlying skin and subcutaneous tissues.^[20] The anterior auricular branch nourishes periauricular tissues, including the anterior aspect of the auricle such as the helix, antihelix, and lobule, facilitating blood flow to the external ear's cartilaginous framework.^[21] Additionally, the zygomatico-orbital branch supplies the orbicularis oculi, while the middle temporal branch perfuses the temporalis muscle and its fascia.^[4] The STA forms anastomoses with branches of the maxillary artery (via the deep temporal arteries), the occipital artery (through parietal connections), and the ophthalmic artery (via supraorbital and supratrochlear routes), enabling collateral flow across superficial and deeper head circulations.^[11] Overall, this vascular territory focuses on superficial integumentary and muscular elements of the lateral head, distinct from deeper facial supplies.^[4]

Role in head circulation

The superficial temporal artery (STA) plays a critical role in the collateral circulation of the head by forming key anastomoses with branches of the internal carotid artery, particularly through its frontal branch connecting to the supraorbital and supratrochlear arteries derived from the ophthalmic artery.^[20]^[11] These connections establish potential pathways for alternative blood flow, enabling retrograde perfusion from the internal carotid system to the external carotid territory in cases of external carotid occlusion, thereby maintaining overall head circulation integrity. This collateral network contributes to hemodynamic stability, particularly in the anterolateral scalp and facial regions, where the STA serves as a major conduit for blood distribution. In scalp circulation, the STA provides a significant contribution to the anterolateral blood supply, dominating perfusion in the anterior temple and parietal areas through its terminal frontal and parietal branches, which form an extensive anastomotic network with contralateral and posterior vessels.^[22] Retrograde flow within these branches can occur during localized ischemia, allowing compensatory influx from adjacent arterial sources to sustain tissue viability.^[23] The artery's pulsatility is readily palpable along its course over the zygomatic arch, where its pulse waveform directly reflects systemic cardiac output variations and serves as a reliable indicator for assessing peripheral perfusion status in clinical evaluations.^[2]^[20] The STA maintains consistent blood flow to the scalp despite fluctuations in systemic pressure through intrinsic autoregulatory mechanisms, primarily the myogenic response in its vascular smooth muscle, which induces vasoconstriction or dilation in response to transmural pressure changes.^[24] This response ensures stable perfusion to superficial tissues under varying hemodynamic conditions. Additionally, the STA integrates closely with the venous system, running parallel to the superficial temporal vein in a contiguous, wavy course that facilitates efficient drainage of the supplied scalp and facial territories, thereby influencing local venous hemodynamics and preventing stasis.^[20]

Clinical significance

Diagnostic procedures

The superficial temporal artery is commonly assessed through temporal artery biopsy, which serves as the gold standard for diagnosing giant cell arteritis (GCA).^[25] This procedure involves excising a segment of the artery, typically 2-3 cm in length from the frontal branch, under local anesthesia to evaluate for characteristic histopathological features such as granulomatous inflammation and giant cells.^[26] Unilateral biopsy yields a sensitivity of 80-90% for GCA when performed promptly, ideally within one week of initiating corticosteroid therapy to minimize false negatives due to skip lesions.^[27] Pulse palpation provides a simple, non-invasive initial evaluation of the superficial temporal artery's patency by gently pressing at the temple just anterior to the ear.^[9] A diminished or absent pulse may indicate underlying pathology, such as atherosclerosis or vasculitis, prompting further investigation.^[28] Doppler ultrasound is a key non-invasive imaging modality for assessing the superficial temporal artery, measuring blood flow velocity—typically 40-60 cm/s in normal conditions—and detecting abnormalities like stenosis or occlusion through elevated peak systolic velocities or the "halo sign" indicative of vessel wall edema.^[29] It is often employed prior to biopsy to confirm arterial patency and guide the procedure site.^[30] Digital subtraction angiography offers detailed visualization of the superficial temporal artery's course and branches, particularly useful in evaluating occlusive diseases by highlighting stenoses or collateral flow patterns.^[31] Indocyanine green angiography is an emerging intraoperative technique for real-time assessment of superficial temporal artery perfusion, especially in reconstructive or aesthetic procedures involving forehead flaps, where it aids in identifying vessel patency and optimizing flap viability.^[32]

Surgical applications

The superficial temporal artery (STA) serves as a primary donor vessel in superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery, particularly for treating cerebral ischemia in conditions such as moyamoya disease. This procedure involves an end-to-side anastomosis, typically using the frontal branch of the STA to a cortical branch of the middle cerebral artery, to augment blood flow to ischemic territories. Clinical outcomes demonstrate high efficacy, with studies reporting excellent or good results in approximately 92% of adult patients with moyamoya disease, including significant reduction in transient ischemic attacks and stroke events.^[33] In reconstructive surgery, the STA supplies the temporoparietal fascial flap, which is widely used for repairing defects in the head and neck, such as those following tumor resection or trauma in the scalp, auricle, orbit, oral cavity, and skull base. The flap is harvested as a pedicled unit based on the STA, allowing rotation with a vascular pedicle length of approximately 4-6 cm from the tragus to the superior temporal line, providing reliable perfusion over distances up to 12-14 cm for moderate-sized defects.^[34]^[35] For the management of complex cerebral aneurysms, particularly those involving the middle cerebral artery or internal carotid artery, the STA enables indirect revascularization through bypass to distal vascular territories, often as part of a multimodal approach including parent vessel occlusion. This technique addresses ischemia risk in aneurysms unsuitable for direct clipping or coiling, with STA-MCA bypass serving as the standard extracranial-intracranial revascularization method to maintain flow in affected regions.^[36]^[37] In aesthetic surgery, the STA's course must be preserved during temporal lifts to avoid ischemia in the temporal skin and fascia, as dissection near the artery can compromise local blood supply and lead to complications like tissue necrosis. Conversely, in facial fat grafting procedures for temporal augmentation, awareness of the STA enhances safety by guiding injection planes away from the vessel, thereby supporting graft vascularization and reducing risks such as embolism.^[38]^[39] Although the STA can provide endovascular access for cerebral angiography or interventions, its use is rare due to frequent tortuosity and potential for kinking, which complicates catheter navigation and increases procedural risks compared to femoral approaches.^[40]^[41]

Pathological conditions

The superficial temporal artery (STA) is frequently involved in giant cell arteritis (GCA), a systemic vasculitis affecting medium- and large-sized arteries in individuals over 50 years old, where inflammation of the arterial wall can cause thickening, narrowing, and ischemia. Clinical manifestations include unilateral or bilateral temporal headaches, scalp tenderness, jaw claudication during mastication, and elevated risk of vision loss from anterior ischemic optic neuropathy if untreated. The STA is prominently affected in cranial GCA, with biopsy often revealing granulomatous inflammation and multinucleated giant cells confirming the diagnosis.^[42]^[43]^[44] Atherosclerosis in the STA is uncommon compared to other arteries but can lead to plaque accumulation, stenosis, and reduced pulsatility detectable on palpation, particularly in patients over 50 with risk factors such as smoking, hypertension, and hyperlipidemia. This condition may contribute to localized ischemia or serve as a predisposing factor for pseudoaneurysms, though it rarely causes overt symptoms unless advanced.^[45]^[46] Traumatic injury to the STA, often from blunt head trauma such as zygomatic arch fractures or sports-related impacts, can result in pseudoaneurysm formation, characterized by a contained hematoma that presents as a painless, pulsatile subcutaneous mass in the temporal region developing days to weeks post-injury. These lesions arise from partial arterial wall disruption allowing blood leakage into surrounding tissues, with rupture risk leading to hematoma expansion or hemorrhage if untreated.^[47]^[48]^[49] Embolic occlusion of the STA or its branches, typically originating from cardiac sources like atrial fibrillation or valvular disease, can cause distal ischemia manifesting as localized scalp necrosis, non-healing ulcers, or patchy alopecia due to compromised blood supply to the galea and skin. Such events are rare but documented in systemic embolic syndromes, where microemboli lodge in smaller vessels, leading to tissue infarction without collateral compensation.^[50]^[51] Iatrogenic injury to the STA occurs during procedures such as rhytidectomy (facelift) or temporal artery biopsy, potentially resulting in arterial laceration, hematoma formation, or skin flap necrosis from disrupted perfusion. In facelifts, dissection in the temporal region risks vessel transection, while biopsies may cause pseudoaneurysm or bleeding if the artery is inadvertently damaged.^[52]^[53]^[54]

References

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Your superficial temporal artery sends blood to your scalp and face. It starts below your ear and runs vertically between your cheekbone and your ear.
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The superficial temporal artery is a terminal branch of the external carotid artery. It originates at the level of the neck of the mandible.
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### Summary of Superficial Temporal Artery
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The superficial temporal artery (STA) is a terminal branch of the external carotid artery. It supplies the regions of scalp and face.Missing: tortuous duplication<|separator|>
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Blood Supply and Lymphatics The auricle is irrigated by the superficial temporal artery anteriorly (toward the tragus) and the posterior auricular artery ...
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[50]
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[53]
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[54]
Surgical anatomy of the superficial temporal artery to prevent facial ...
... iatrogenic injury. In conclusion, when performing an FSTA biopsy, the surgeon should not dissect below the superficial temporal fascia because there is an ...Missing: facelift | Show results with:facelift