Your Questions
Your Questions
Q: Dr. Eppley, I am interested in temporal artery ligation. My right temporal artery is considerably larger than the one on my left. Although both are unsightly and bothersome. I have become very self conscious of them. And the are affecting my daily life. At normal rest they are slightly visible. They become increasingly larger and more noticeable when I exercise, when its warm, and when I consume alcohol. And not much alcohol either ! Just a few sips of beer or wine. They even enlarge when I’m talking a lot.
A: Your description of prominent temporal arteries is classic. Prominent temporal arteries can be successfully reduced, and some times completely eliminated, by temporal artery ligation. The secret is to locate the pattern of flow into the visible artery and do ligations both anterograde and retrograde. This is a bit of an art form and, while every temporal artery ligation procedure shows immediate improvement, the real test of the effectiveness of the procedure is what it is like 3 to 6 months afterward.
Temporal artery ligation is a procedure done under local anesthesia in an office setting. Each small access incision for ligation is about 5 to 7mms in length. There is no bruising afterwards with minimal swelling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about temporal artery ligation. I have two prominent vessels on my temples. They are actually not veins. It’s a temporal artery on both sides of my head. I’ve spoken with two doctors who said to leave it alone. Here are pictures of them. I was told these are arteries, not veins. Both doctors told me that they should not be removed as they supply blood flow. Sometimes they’re not very visible but that’s usually when I’ve just woken up in the morning. I have a little bit of high blood pressure and I’m on medication for it. Anyhow, I’m not really sure what to do. I didn’t have these a few years ago but as I’ve gotten older they’ve gotten worse. I really don’t want to have permanent scars from a procedure.Thanks.
A: Thank you for sending your temporal pictures. These are classic enlarged anterior temporal branch arteries from the bifurcation of the main trunk of these superficial temporal artery. They will be more noticeable with your blood pressure is higher, when exercising or when in hotter temperatures due to the increased blood flow in them. Whether you have them treated by temporal artery ligation to reduce their visibility is a personal decision. But if you were to do so, this is a perfectly safe procedure that is done through very small incisions in the temporal hairline and possible a very tiny one at its end at the side of the forehead. These small incisions do not create scarring concerns. The forehead and scalp have such a redundant and extensive network of blood supply that reducing flow through these vessels will not cause an harm in so doing.
Dr. Barry Eppley
Indianalpolis, Indiana
Q: Dr. Eppley, I am very excited about finding your webpage, discovered by searching for ways/methods to remove/hide my two bulging temple veins/arteries. They are very prominent, especially when in the sun, after exercise, after an alcoholic beverage, in a hot room, or after a salt-enriched meal. Been dealing with these for 15 years and I am ready to just pull them out. I am bald and shave the rest of my head, so their prominence is highly noticeable and “causing a complex” doesn’t begin to describe the frustration and discomfort in my life . After seeing the explanation of the temporal augmentation process, with the photo of the man’s head with the incision and implant on is temple, I have a few questions. I am curious if the temporal augmentation implant can be placed in between the temple arteries and the skin? Thus putting a shield over the vein and permanently keeping it masked to never be seen again. If yes, you have answered my prayers. If yes, how big is the incision? Thank you for any information that can help me.
A: In eliminating or decreasing the appearance of temporal arteries, you can not put any implant between them and the skin for a number of reasons including risk of arterial rupture, visibility of the implant’s outline through the skin and the length of the incision needed to place them. In theory one could use that ‘camouflage’ approach with fat injections but I doubt that would be very effective and would create its own lumpy appearance issues. The proven treatment for prominent temporal arteries is multiple point temporal artery ligation that is done through several very small incisions. Temporal artery ligation is a procedure done under local anesthesia in the office after tracing out the pathway of the prominent temporal arteries.
I would need to see some pictures of your prominent temporal arteries to see if temporal artery ligation would work for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a plastic surgeon and I did some internet search on options for treating prominent temporal artery and I came across your opinions and website. I have chatted with a few of my colleagues and seniors and nobody seems to have experience with this ! Have you had success in treating the prominence with temporal artery ligation? I have a bald male patient who is very bothered by the prominence and is looking at surgical options. I would totally appreciate it if you would give me your opinion on the temporal artery ligation procedure.
A: This is a procedure that I have done many times and with good success. It is not, however, performed as has been historically done for temporal artery ligation for temporal arteritis or for temporal artery biopsies. It requires careful tracking of the arterial branches with multiple ligation points to prevent back flow and to get any feeders coming into the main anterior branch of the superficial temporal artery. The other key element of the procedure is that the incisions must not exceed 5mms in size and requires loupe magnification and head light to meticulously work through such small incisions and tie off the small arterial branches. One must also be prepared to venture out into the forehead to get the distal branches and do careful dissections to avoid the frontal branch of the facial nerve.
While not every case of multiple point temporal artery ligation will result in complete elimination of the prominent vessel, it always results in significant reduction in their visibility.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had contacted you months ago inquiring about temporal artery ligation. But I had to reconsider that procedure because the artery on my left side now appears when doing physical activities or with heat but not as bad as the right. And even down the middle of my forehead. So now I was wondering if you do fat transfers to the entire forehead and if you thinks this could help with my appearance. It seems that I suddenly have lost fat in my forehead which is making these arteries appear worse.
A: Fat transfer is not known to be an effective treatment to camouflage prominent forehead arteries and veins. While this seems like it would work, it does not in my experience. This is because it is difficult, if not impossible, to put the fat on top of the arteries. Rather it ends up going around them and does not result in decreasing theie visibility. Temporal artery ligation is the best approach for prominent arterial vessels of the temporal and forehead area. It is also far simpler as it directly treats the problem…the vessel themselves.
Temporal artery ligation is usually done under local anesthesia using small 5mm incisions to isolate the arterial branches and tie them off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal artery ligation. There are a few pics of how it looks just about everyday when I exercise it gets about 3-4 times worse and throbs rapidly. I went to the doctors and they said that its common and since I’m a big guy at 6’4 and 240 lbs that it’s not uncommon and there really is no treatment. When researching online it suggests prednisone in a large dose along with other things. I’m not sure if I should seek another doctor opinion or if prednisone is something that is going to help with it.The arteries being prominent drive me a bit crazy I know they are super noticeable and I get a comment here and there about them which is frustrating to say the least. How much does surgery cost? And would it be wise to try out the prednisone if I can find a doctor who thinks that would help.
A: Your prominent temporal arteries show a very classic pattern along the squiggly pattern of the anterior branch of the temporal artery. I have not heard of using steroids for reducing the appearance of prominent temporal arteries. That is the type of treatment for temporal arteritis but that is not what you have. The only successful treatment for their reduction in multiple point ligation. That is a procedure done under local anesthesia in the office. I will have my assistant pass along the cost of the surgery to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Interested in advice on upside and the downside of temporal artery ligation. I am a healthy 39 year old male and have these arteries near both temples that constantly bulge and have a pulse in the heat, under stress or when exercising. They look like squiggly worms on the side of my head!
A: Prominent temporal arteries are not rare and their presence becomes more noticeable when the need for increased blood flow occurs. (exercising, heat or just bending over) Temporal artery ligation for cosmetic purposes is done through very small incisions in the temporal hairline and usually one at the end of the visible arteries location. (which is usually somewhere close to the forehead) Always two separate points of ligation are done and occasionally three ligation points are required. These small incisions heal imperceptibly and are not a cosmetic problem. The procedure is done in the office under local anesthesia and there is no real recovery at all. One can resume all activities right after the surgery. the only potential downside to temporal artery ligation is in how well it works. The appearance of the temporal artery can definitely be reduced but not always completely eliminated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, . I have seen you have had experience with temporal artery ligation and success dealing with this procedure in the past which is why I am contacting you. Attached is a picture of my problem. The artery gets larger if my heart rate is up or its hot outside. I have another one that is not as bad on my left side as well that I would like to deal with at some point if the initial procedure works. Is the success rate of this procedure pretty high, in terms of greatly minimizing the size of the entire artery? I am very interested in having this procedure done.
A: The success rate of temporal artery ligation in my experience is always 100% or very close. That would be expected when you shut down both ends of the pipe so to speak. That is actually not the question that is the most relevant. The more relevant question is…does collateralization or shunting of flow occur? This means if you shut down one section of the pipe way will other previously invisible sections of the pipeline appear later. It is important to remember that all the arteries in the scalp and forehead are very extensive and interconnected. So in theory the blood flow that went to the vessel that was shut down could be shunted and cause vessel dilation elsewhere. I only mention this point in cases of men that shave their head where the entire scalp can be seen. I have had a few patients contact me over the years who had their temporal arteries ligated elsewhere and they developed visible dilated vessels elsewhere in the scalp weeks to months later which they felt was a worse aesthetic problem than the one they had treated. This shunting is not a problem that I have seen with temporal arerty ligation but it is one of which to be aware and a potential risk of the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about temporal artery ligation. You have mentioned that the ligation of the temporal arteries would not cause hair loss. So, I’m 18 years old and I started to get a receding hairline and some slight thinning. Is it possible that these ligations don’t cause immediate hair loss, but accelerate the process of male pattern baldness? The internet says weird things, some sites claim that you should increase oxygen in the scalp and that bald people have less blood circulation/oxygen in their scalp. On the other hand, I came across a study that claims that ligation of the temporal arteries would stop male pattern baldness. I’m very confused and I was interested if you’d have an answer.
A: Hair loss, in general, is genetically driven. There is no medical evidence in an otherwise normal scalp that changing oxygen levels affects how the hair grows or how long it is retained. The scalp is so richly oxygenated by an extensive vascular system that it is impervious to varying oxygen levels throughout the body. A simple example of that concept is the effect seen in smokers who have lower blood oxygenation levels but often have very full heads of hair throughout their life. In addition, if oxygenating the scalp was beneficial for hair loss prevention there would be many scalp treatments available that offer that exact therapy. While the topical drug Minoxidil (Rogaine) does improve hair growth and hair loss prevention, it has a very specific vasodilatory effect on the hair follicle itself.
As it relates to temporal artery ligation, there again is no evidence that it has any effect on hair growth patterns…either a positive or negative effect. However, because of its collateral circulatory effects and employing the principle of choke vessels, a conservative approach to temporal artery ligation would be to do one side at a time. This is more an approach to ensure there is no negative effect on scalp skin survival and not necessarily for its effect on hair growth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to get the ligation of the temporal arteries done. I’ve heard from you from a forum on the internet with lots of success stories. But I still have a couple of questions. If you tie off the artery at several locations, isn’t it possible that there appear ‘new’ artery or that the capillary system ‘feeds’ the tied off artery, so blood returns to the artery? Is there any chance of hair loss? My temporal arteries bulge beyond my hairline, how can you determine to ligate it in the hair bearing region? How big are the scars? On my right there’s just ‘one’ artery, while the one on the left splits into three arteries, of whom 2 splits into 2 other very little arteries, so I’d need a lot of ligations on this side.
A: When it comes to temporal artery ligation, the key is to perform proximal ligation to cut off the very high anterograde flow and distal ligations of any identifiable branches to eliminate any retrograde flow. If all lines that feed into the visible ‘pipes’ are tied off, there is no way any blood flow can return to the artery. There is no capillary system that feeds into the arteries. This always requires an incision (10mms) in the temporal hairline and small incisions (5 – 7mms) beyond it in the forehead area wherever the distal and feeder branches cab be identified. There is no risk of hair loss with this procedure. The blood flow to the scalp is extensive and has many other feeder vessels for scalp and hair survival. If ever in doubt, you only do one side at a time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I found you from an internet search for “bulging temporal artery”. I have read that you recommend multiple location ligation done in office as the treatment. I do, however, have a few questions for you.
1. The artery doesn’t always bulge. I don’t know what triggers it but there are times it’s almost flat. Can a ligation be done ONLY if it’s bulging? (It can be irritated to swell up by rubbing or me crying)
2. Are there chances of complications? (loss of hair due to lower blood flow? Surrounding arteries swelling from diverted blood flow?) The internet has scary scenarios!
3. How would I attend follow up appointments for stitch removal etc since I’m 4 hours away?
4) How long is the recovery time and what can I expect in the way of swelling, bleeding or bruising? (take a week off or more?)
A: In answer to your questions about temporal artery ligation of a bulging or prominent temporal artery branch in the forehead/temple area:
1) It is important to be able to find the temporal artery branch to ligate it. So some degree of bulging is needed for the surgical ligation procedure to find the potential multiple ligation points.
2) Other than some very small scars, the risks of the procedure are merely as to how well it works. There is no risk of hair loss and surrounding arteries become dilated as a result of these ligations.
3) The small suture that are placed are dissolveable so there is no need for any follow-up visits.
4) There really is no recovery of any significance. Other than some small swelling at the ligation points, there are other issues of concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal artery ligation. I have an artery (or arteries) with small broken capillaries around it on the right side of my forehead. It weekly bulges and swells, then goes down a little over five to seven days. This has been going on since January. It never completely disappears. I’ve seen a dermatologist (who will not laser arteries), my general practitioner (who ruled out temporal arteritis) and a vascular surgeon (who says it’s not disease). I then consulted with a plastic surgeon in my area. He said he could ligate at the hairline but when I questioned him about back flow or multiple vessels feeding the bulging area he admitted to being uncomfortable doing the procedure. The vascular surgeon had noted that unless he pressed right where the artery branched off the main one the problem area did not collapse. I feel at a loss. I don’t want to do more harm then good but I’m uncomfortable with it’s appearance. I would love your opinion. Hopefully you can help me. I have attached a picture of the bulging artery.
A: It appears that you have a prominent branch of the anterior temporal artery. You are correct in assuming that it is best t have at least a two point an sometimes a three point ligation approach. That can be determined by an actual physical examination right before or during the procedure. Your plastic surgeon’s concern is the fear of potentially injuring the frontal branch of the facial nerve as it crosses the temporal area between the hairline and the eyebrow on its way to the forehead. Fortunately that small nerve branch runs anterior (in front of) where your bulging artery is located.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, have you ever treated sufferers of migraines caused by (likely) the hard throbbing of the superficial temporal artery. My wife has 5 migraines a week, nearly all of which are in this area. We do not understand the root cause of the pulsations themselves, but it is possible these hard pulsations (lasting hours, or even days on end) are irritating the nerves local to the artery, and becoming interpreted as migraine in the brain. Given that medications (and neurologists and others) offer no relief, and she has suffered for decades, we are exploring procedures. Thank you.
A: While getting to the origin or even finding an effective treatment for migraines is never simple, the simple answer to your question is yes. It is very possible that high flow through the superficial temporal artery (STA) can be a source of migraines. While I would have initially thought it was possible but with a low probability, I recently treated a lady with a 30 year history of refractory migraines of the right temporal region with 2-point ligation of the STA with a dramatic and sustained reduction of her migraines. She felt that the pulsations she was feeling was a major contributor to her migraines and the origins was clearly on the temporal side with very visible pulsations. Given that there is no risk of any downside to STA ligation and it is a minor procedure with no recovery, it seemed like a reasonable thing to do.
While there would be no guarantee that STA ligationswould be effective for your wife’s migraines, and they should always be done from two points to eliminate recurrent pulsations due to retrograde flow, it would be relatively easy to eliminate this potential source.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 57 year old male in good health, who exercises regularly and watches what I eat. Over the last couple of years, my temporal artery on the right side of my forehead has become more pronounced. I visited a vascular surgeon, who said there was no medical reason to do anything. The vessel is very noticeable and I wanted to know if there was anything that could be done to hide it. I am concerned because the surgeon said its removal could cause other issues (eyelid drooping).
A: Ligation of the branches of the superficial temporal artery (STA) can be done to reduce its prominence. The main trunk of the STA lies in the temporal hairline and is far removed from any branch of the facial nerve. But reduing anterograde (forward flow) of the STA is usally not eough to reduce its visible pulsatile appearance. Retrograde (backward flow) from the STA from its distal extension in the forehead must also be done. (two-point ligation) This is done through a small stab incision somewhere on the forehead where the tail of the visible artery can be seen. This also has a very low risk of injury to the frontal branch of the facial nerve which supplies the forehead and upper eyelid closure.
Dr. Barry Eppley
Indianapolis, Indianapolis