Mapping the lingual artery: a scoping review and proposed imaging-informed risk classification for surgical and radiological practice

BACKGROUND: The lingual artery (LA) shows significant morphological and topographical variation that can affect the safety and results of head and neck surgeries, carotid interventions, and free flap reconstructions. Traditional descriptions such as the thyrolingual trunk (TLT), linguofacial trunk (LFT), and thyrolinguofacial trunk (TLFT) do not consider surgical risk assessment or the importance of modern imaging. OBJECTIVE: To comprehensively review LA origin and course variants, determine their prevalence in cadaveric and imaging datasets, and propose an imaging-informed, anatomy-based risk classification for surgical and radiological use. METHODS: A PRISMA Extension for Scoping Reviews (PRISMA-ScR)-aligned scoping review of PubMed, Scopus, and Web of Science (January 2007-May 2025) identified studies reporting LA variants through cadaveric dissection, computed tomography angiography (CTA), magnetic resonance angiography (MRA), or digital subtraction angiography. Only original studies in English containing primary variant data were included. Prevalence ranges were extracted, and a proposed anatomy-based classification (Classes I-III) was constructed according to branching pattern, shared trunk involvement, proximity to the carotid bifurcation or common carotid artery, and anticipated implications for vascular control. Because standardized clinical outcome data were inconsistently reported across the included studies, the framework should not be interpreted as outcome-validated. RESULTS: Ten eligible studies (n = 1550 ECAs) from Europe, Asia, North America, and Africa were included from cadaveric and imaging datasets. Typical anatomy with independent STA, LA, and FA origins was found in 50.7-90% of cases. LFT occurred in 7.5-24.3%, TLT in 0.6-10.5%, TLFT in 0-2.85%, and aberrant origins from the CCA or carotid bifurcation (ALA) in 0.7-6.6%. In the original course-variant dataset (n = 111 body sides), superficial, submental, and dual-origin variants were each uncommon. CTA provided the most detailed three-dimensional depiction of moderate- and high-complexity variants in the included imaging studies. The proposed classification organizes origin and course variants according to expected procedural complexity and imaging needs. CONCLUSIONS: A substantial proportion of patients present with LA variants that may influence surgical planning and intraoperative decision-making. The proposed classification may serve as an imaging-informed, clinically oriented framework for preoperative evaluation and multidisciplinary communication. However, it remains anatomy-based and requires prospective clinical validation before outcome-based application.