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Facial Nerve Injury: A Complication of SuperficialTemporal Artery Biopsy

MICHAEL K. YOON, JONATHAN C. HORTON, AND TIMOTHY J. MCCULLEY

● PURPOSE: To describe 4 patients who sustained facialerve injury during temporal artery biopsy.

● DESIGN: Retrospective, observational case series.● METHODS: The medical records were reviewed of 4patients (2 men, 2 women; mean age 72.8 years, range 60to 87), referred for evaluation of palsy of the frontalbranch of the facial nerve following temporal arterybiopsy. Main outcomes measured were site of incision,length of follow-up, and degree of recovery.● RESULTS: In all cases, incisions were made in thepreauricular region or on the pretrichial temple within3 cm of the lateral canthal angle. Follow-up rangedfrom 1 month to over 5 years. No patient recoveredcompletely; 2 had partial return of function, and 2reported no improvement.● CONCLUSIONS: Branch facial nerve palsy can occurwith temporal artery biopsy and is likely to result inpermanent disability. In all cases the incision was placedwithin the known course of the frontal branch of thefacial nerve. To prevent this rare complication, weadvocate biopsy of the parietal, rather than the frontal,branch of the superficial temporal artery. (Am J Oph-thalmol 2011;152:251–255. © 2011 by Elsevier Inc. Allrights reserved.)

G IANT CELL ARTERITIS (GCA) IS AN IDIOPATHIC

vasculitis that affects medium- to large-sized ar-teries throughout the body. Long-term immune

suppression, most often with prednisone, remains themainstay of therapy. Particularly in elderly patients, thisdrug carries significant risk of complications. Therefore,prior to assigning the diagnosis of GCA, histopathologicconfirmation is desirable. Biopsy of the superficial temporalartery remains the gold standard for diagnosis and isgenerally felt to be a low-risk procedure. However, bothminor and more serious complications have been de-scribed.1–6 In this report, we describe 4 patients with injuryto the facial nerve, which occurred during temporal arterybiopsy.

Accepted for publication Feb 2, 2011.From the School of Medicine, Department of Ophthalmology, Uni-

versity of California at San Francisco, San Francisco, California (M.K.Y.,J.C.H., T.J.M.). Timothy J. McCulley is currently practicing at WilmerEye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland,USA, and is also affiliated with King Khaled Eye Specialist Hospital,Riyadh, Saudi Arabia.

Inquiries to Timothy J. McCulley, The Wilmer Eye Institute, JohnsHopkins School of Medicine, 600 North Wolfe Street, Wilmer 110,

Baltimore, MD 21287; e-mail: tmccull5@jhmi.edu

© 2011 BY ELSEVIER INC. A0002-9394/$36.00doi:10.1016/j.ajo.2011.02.003

METHODS

A RETROSPECTIVE, OBSERVATIONAL CASE SERIES WAS

compiled by reviewing the records in the tertiary careneuro-ophthalmology practices at the University of Cali-fornia–San Francisco from October 1, 2004 to January 31,2009. Four patients (2 male and 2 female, mean age 72.8years, ranging from 60 to 87) who had been specificallyreferred to our department for evaluation of facial nerveinjury following temporal artery biopsy were included.Medical records were reviewed with particular attentiongiven to the site of incision, length of follow-up, and thedegree of spontaneous recovery. Other causes of facialnerve palsy, including idiopathic and post-neurosurgical,were not included. Attempts were made to acquire theoperative reports from the referring practices.

A PubMed search using the term “temporal arterybiopsy” was performed and any reports addressing com-plications were assessed. Three cases of facial nerveinjury were identified and were compiled with the casesfrom this series. Site of incision and degree of recoverywere noted.

RESULTS

THE TABLE SUMMARIZES THE RESULTS. ONE PATIENT WAS

referred from an ophthalmologist, 1 from a general plasticsurgeon, and 2 from vascular surgeons. Each patient wasreferred from a different physician. Only 1 operative notewas available for review, and this did not documentdifficulty with the surgery or abnormalities in the anatomy.

Three patients had unilateral and 1 had bilateral super-ficial temporal artery biopsies. In the patient with biopsiesperformed on both sides, only the right side was injured.On initial evaluation, complete loss of brow elevation andpartial loss of eyelid closure were observed. Patients hadbiopsy in the pretrichial temporal (n � 3) or preauricular(n � 1) regions (Figures 1 through 4). In the 3 cases withincisions performed in the pretrichial region, the incisionextended to within 3 cm of the lateral orbital rim.Improvement (based on self-reporting and clinical evalu-ation) in frontalis function ranged from zero to 75 percent.Follow-up ranged from 1 month to 5.5 years (mean 1.8years). No patients underwent surgery or other therapy tocorrect brow position. There were no other significant

complications.

LL RIGHTS RESERVED. 251

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Three previously reported cases were identified withreview of the literature and were included in the Table foromparison. Including these patients in our series gave aotal of 7 patients (3 male, 4 female, mean age 69.1 years,ange 55 to 87 years). Recovery of function ranged fromero to 75 percent.

DISCUSSION

LITTLE ATTENTION HAS BEEN GIVEN TO THE POTENTIAL

consequences of superficial temporal artery biopsy, sincemost physicians believe that complications are rare andinconsequential. Reported complications include visiblescarring, hematoma, wound infection and dehiscence,skin necrosis, and the most severe, a cerebral infarction,presumably attributable to dependent collateral bloodflow to the brain via the superficial temporal artery.1–3,7

Facial nerve injury has been previously reported as aconsequence of superficial temporal artery biopsy.4–6 Inach of the 3 cases, operative notes describe technicalifficulties with the procedure. One report noted the

TABLE. Summary of Branch Facial Nerve Palsy After SuperR

Patient Age (Years) Sex Site of Bio

1 78 M Temporal

2 60 F Pre-auricular

3 87 M Temporal

4 66 F Temporal

Study mean 72.8

Slavin 1986 55 F Temporal

Bhatti 2000 63 F “Temporal scal

Bhatti 2001 75 M Temporal

FIGURE 1. Patient 1 demonstrating right frontalis palsy aftersuperficial temporal artery biopsy. The biopsy site in thepretrichial region is covered by the bandage.

issection to be “more extensive than usual,” another a

AMERICAN JOURNAL OF252

equired 2 separate incisions, while the third describedifficulty attributable to “the nature of the tissues.” Fur-hermore, the incision was made within a few centimetersf the lateral orbital rim.The incidence of facial nerve trauma during superficial

emporal artery biopsy is not known, although it is pre-umed to be quite rare. Guffey Johnson and associatesound 1.25 percent of specimens submitted as temporal

Temporal Artery Biopsy Cases: Current Study and Previouss

Surgeon Specialty Follow-up Recovery

Ophthalmology 1 month None

Vascular surgery 5.5 years 10%

Vascular surgery 9 months 75%

Plastic surgery 9 months None

1.8 years

Not listed 6 month 70%

ion” General surgery 1 month None

General surgery 6 months None

FIGURE 2. Patient 2. (Top) Patient 2 demonstrating leftfrontalis palsy after superficial temporal artery biopsy. (Bot-tom) The shaded area delineates the “danger zone.” Adhesivetape covers the preauricular incision.

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rtery biopsy contained vein or peripheral nerve (presum-

OPHTHALMOLOGY AUGUST 2011

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ably sensory), rather than a muscular artery.8 The func-ional consequence of this was not provided. This findingtresses the potential difficulty accurately distinguishinghe artery intraoperatively.

Recovery of frontalis function after biopsy-relatednjury was variable. In our series, 3 patients were

FIGURE 3. Patient 3 demonstrating right frontalis palsy aftersuperficial temporal artery biopsy. Arrows denote the healedpretrichial incision site.

FIGURE 4. Patient 4. (Top) Patient 4 demonstrating leftfrontalis palsy after superficial temporal artery biopsy. (Bot-tom) Arrows denote the healed pretrichial incision site.

ollowed for 9 months or more. Of these, 1 reported 75%

FACIAL NERVE INJURY FROM SUPERFIVOL. 152, NO. 2

ecovery, 1 reported 10% recovery, and the other had noeturn of facial nerve function. The patient who wasbserved for only 1 month had no return of function,ut that time interval is too brief to draw any conclu-ions. The variability of recovery is consistent withreviously published reports, which spanned from zeroo 70 percent return in function.4 – 6 The degree of

recovery likely relates to the exact mechanism of injury.Inadvertent cautery or stretching of the nerve wouldseem more likely to produce transient or partial injury,whereas in those with complete and permanent injury,the nerve was likely severed. Admittedly, this is specu-lative as no surgeon acknowledged awareness that thenerve was injured intraoperatively.

Immediately anterior to the tragus, in the preauricularregion, the branches of the facial nerve run deep to theparotid gland. The frontal branch crosses the zygomaticarch approximately 2.5 cm anterior to the tragus,heading in a superoanterior direction. At this level,branches of the facial nerve run in the innominate fascia,

FIGURE 5. Schematic of the course of the superficial temporalartery and facial nerve. The artery typically bifurcates into ananterior frontal branch and posterior parietal branch. Thetemporal branch of the facial nerve courses deep to thesuperficial temporal fascia within the “danger zone” (shadedgray). The more posterior parietal branch of the superficialtemporal artery, rather than frontal branch, therefore providesa readily accessible and safer biopsy location. (Illustrationcourtesy of Lynda McCulley, PharmD).

a fibro-fatty layer deep to the superficial temporal fascia, for

CIAL TEMPORAL ARTERY BIOPSY 253

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a distance of 1.5 to 3.0 cm. Then, as the nerve continuessuperiorly, it becomes superficial and courses immediatelydeep to the superficial temporal fascia9 (Figure 5). In theretrichial temple, anterior to the hair line, the nerveranch is approximately 0.9 to 1.4 cm posterior to theateral orbital rim. The nerve terminates by innervatinghe frontalis, orbicularis oculi, and corrugator supraciliarisuscles.Similar to the facial nerve, the superficial temporal

rtery is deep to the auricularis anterior muscle in thereauricular area. After crossing the zygomatic arch, thertery runs within the superficial temporalis fascia. Inhe majority of patients, the superficial temporal arteryranches into a frontal and parietal ramus approxi-ately 2.5 cm superior to the zygomatic arch.10 The

rontal ramus of the artery travels anteriorly, deep to theretrichial temple skin. However, the parietal ramus hassuperior and posterior course relative to the tragus.The “danger zone” was noted as an area of the temple

here the frontal branch of the facial nerve and the frontalamus of the superficial temporal artery are separated inepth only by a partial layer of fascia, the superficialemporal fascia. This area is bounded by (A) the tragus ofhe ear, (B) the junction of the zygomatic arch and lateralrbital rim, (C) the area 2 cm superior to the superiorrbital rim, and (D) the point superior to the tragus and inorizontal alignment with (C).11 The best strategy forvoiding damage to the nerve is to obtain a segment ofhe artery that is outside the “danger zone.” Because of theotential for frontalis paresis, we prefer to biopsy thearietal branch if possible.Some surgeons may elect to biopsy the frontal branch

ecause of its readily identifiable location on hairlessemple skin. The layer of subcutaneous fat is thinnerhan that overlying the parietal ramus, making theerve more easily palpable. Underlying hairless skin,he frontal ramus is in fact visible in many patients. Thedded thickness of the subcutaneous fat and the pres-nce of hair make the parietal branch more challengingo locate. As advocated by others, we often use aandheld Doppler ultrasound to map the course of thertery.12,13 Accurately plotting the course of the arteryimits the need for extensive dissection, decreasing theisk of damage to the facial nerve. If the artery cannot beasily located, intraoperative ultrasound using a sterile

leeve over the probe can be helpful. The presence of r

AMERICAN JOURNAL OF254

air is a deterrent in some surgeons’ opinion. Weoutinely shave the hair overlying the parietal ramus.sing an electric razor, this takes less than a minute. An

dded benefit is that any resulting scar is not visiblence the hair has regrown. By shaving the surgicalegion, and identifying the artery with Doppler whenecessary, the parietal ramus can be easily biopsied.Rarely, when biopsy of the frontal branch of the

uperficial temporal artery is necessary (because ofalpable nodules within the artery,14 previous parietalamus biopsy, or essential cerebral collaterals based onngiography15), injury to this area may be minimized by

carefully identifying the artery of interest, using Dopplerultrasound if necessary. Meticulous surgical techniqueshould be employed, maintaining hemostasis to allow forcomplete visualization of tissues and judicious bluntdissection without penetrating the superficial temporalisfascia.

Studies specifically addressing the relative sensitivityof biopsies obtained from the temporal and parietalbranches of the superficial temporal artery have notbeen performed. However, GCA is a systemic processand pathologic evidence of inflammation has beendemonstrated in numerous locations, including theoccipital artery,16 facial artery,17 and arteries of thenternal carotid circulation.18,19 Therefore there is noeason to think that biopsy of the parietal branch is anyess useful in assessing the presence of GCA than itsnterior counterpart.

This study is limited by biases inherent to all retro-pective studies. For example, the severity of injury maye exaggerated. Patients with less severe injury whonjoy a complete recovery might be less apt to beeferred and therefore go undetected. Also, measure-ent of the degree of recovery is not precise and is based

imply on clinical impression. Photographs taken at theime of injury and at the last follow-up visit were notonsistently available and could not be assessed. Finally,iven the tertiary referral nature of our practice, selec-ion bias may have occurred.

Although rare, this potential complication should beonsidered when recommending a superficial temporalrtery biopsy. Surgeons can minimize the risk withroper surgical site selection and knowledge of the

elevant anatomy.

PUBLICATION OF THIS ARTICLE WAS SUPPORTED BY AN UNRESTRICTED GRANT FROM RESEARCH TO PREVENT BLINDNESS,New York, New York, to the University of California – San Francisco. The authors indicate no financial support or financial conflict of interest. Involvedin design of the study (T.J.M.), conduct of the study (M.K.Y.), collection of data (M.K.Y., J.C.H., T.J.M.), management of data (M.K.Y.), analysis ofdata (M.K.Y.), interpretation of data (M.K.Y., J.C.H., T.J.M.), preparation of the manuscript (M.K.Y.), review of the manuscript (M.K.Y., J.C.H.,T.J.M.), and approval of the manuscript (M.K.Y., J.C.H., T.J.M.). Institutional Review Board approval was waived due to the retrospective nature ofthis study. There was complete adherence to the Declaration of Helsinki and all federal and state laws.

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Biosketch

Michael K. Yoon, MD, is a fellow in oculofacial plastic surgery and neuro-ophthalmology at the University of California– San Francisco. After completion of a combined seven year accelerated medical program at Union College and AlbanyMedical College in 2004, he finished internship at Harbor-UCLA Medical Center. His ophthalmology residency was atTufts-New England Eye Center in Boston. His interests lie in the management of orbital disease, and he plans on a careerin academic medicine.

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