Buccinator Musculomucosal Flap Applications in Intraoral Reconstruction

ORIGINAL ARTICLE Buccinator Musculomucosal Flap Applications in Intraoral Reconstruction

Greg R. Licameli, MD; Robert Dolan, MD

Objective: To evaluate the use of the buccinator mus- without sequelae. No patient experienced difficulties with culomucosal flap in the reconstruction of defects of the mastication or oral competence. All patients reported light oral cavity and oropharynx. single-point touch sensation over the flap 2 weeks after surgery. Cadaveric dissections using latex or india ink Design: Prospective case series of 8 patients during a 1-year injections demonstrated the posterior neurovascular sup- period with an average follow-up of 1 year. Six anatomi- ply from the buccal artery, a branch of the internal max- cal dissections were performed on 3 fresh cadaver heads illary artery, and the buccal nerve, a branch of the man- to investigate the neurovascular supply to the flap. dibular nerve.

Setting: Academic tertiary referral medical center. Conclusions: The buccinator musculomucosal flap is a dependable local sensate flap with a well-defined neu- Results: The buccinator musculomucosal flap was used rovascular pedicle that can be used in a variety of intra- in the reconstruction of 8 defects of the oral cavity, ret- oral reconstructions obviating the need for distal tissue romolar trigone, and soft palate. There was 1 partial flap harvest. necrosis that occurred in a patient who had previously received radiation therapy and who healed secondarily Arch Otolaryngol Head Neck Surg. 1998;124:69-72

OSTERIORLY BASED buccina- cision of a T1, N0 SCC of the left retro- tor musculomucosal flaps molar trigone. The defect was allowed to (BMFs) are useful for oral heal secondarily. A recurrent 1ϫ2-cm le- cavity reconstruction, yet sion was noted within the prior surgical have received little atten- field. Wide excision of this lesion in- tionP in the otolaryngologic literature. In cluded excision of the periosteum of the the past, these flaps were used primarily ascending mandibular ramus and the sub- for reconstruction of cleft palate defects. sequent defect measured 2ϫ3 cm with ex- The application of this flap to common de- posed bone. fects of the posterior oral cavity after can- A BMF was raised intraorally and ro- cer resection has not been reported. The tated on its posterior neurovascular pedicle BMF provides sensate coverage for a va- into the defect. The flap was secured with riety of posterior oral cavity and oropha- slow absorbing sutures and the donor site ryngeal defects, and we have used it for re- was closed primarily. The patient was dis- construction of defects involving the charged home on postoperative day 1 on a retromolar trigone, soft palate, and pos- soft solid diet. The distal tip (3 mm) of the terior floor of mouth. We present this clini- flap underwent necrosis, but the resulting cal experience and results of cadaveric dis- defect healed uneventfully by secondary in- sections to demonstrate the anatomical tention after debridement. Light touch per- basis and clinical applications of the BMF. ception was demonstrated over the flap at the 2-week clinic follow-up. At 1 year of follow-up the patient was free of disease. From the Department of REPORT OF CASES Otolaryngology–Head and Neck Surgery, Boston CASE 1 CASE 2 University School of Medicine, Boston, Mass. Dr Licameli is A 65-year-old man who received prior ra- A 62-year-old man presented with T1, N0 now with the University of diation therapy for a T2 SCC of the tongue SCC of the left soft palate and anterior ton- Illinois at Chicago. presented 9 months after a wide local ex- sillar pillar. On direct laryngoscopy the le-

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 MATERIALS AND METHODS was injected under steady continuous pressure for approxi- mately 15 seconds. Dissections of the buccinator muscle and overlying mucosa were performed via an intraoral ap- Clinical cases were obtained prospectively from the Otolar- proach through a median mandibulotomy. yngology–Head and Neck Surgery Service at the Veterans Affairs Hospital, Boston, Mass, from January 1994 to June SURGICAL TECHNIQUE 1995. Eight patients were selected based on the defect an- ticipated after surgical excision. Seven of the patients were The tumor is excised and the defect is sized (Figure 1 and men and 1 was a woman, with an average age of 66 years. Figure 2). Stensen duct is identified and the superior mar- All patients were staged before excision as having a T1, N0, gin of the flap is outlined, keeping at least 3 mm inferior M0 or T2, N0, M0 squamous cell carcinoma (SCC) involv- to the duct papilla (Figure 3). The anterior limit of the ing the soft palate (2 patients), retromolar trigone (5 pa- flap is 1 cm behind the oral commissure. The maximal graft tients), or floor of mouth (1 patient) (Table). The smallest size possible is 4 cm in a superior-inferior direction and 7 defect measured 2.5ϫ3 cm, and the largest defect was 3ϫ5 cm in an anteroposterior direction. cm. Three patients had prior oral cavity carcinoma; 2 in the The buccal mucosa and the buccinator muscle are in- same site as the resection and 1 with a history of multiple cised to the level of the buccopharyngeal fascia, working small SCCs of the tongue previously excised before present- in an anterior to posterior direction. A loose areolar plane ing with a separate palate lesion. All patients were followed exists between the buccinator muscle and the buccopha- up for a minimum of 1 year after surgery. ryngeal fascia, facilitating the elevation of the flap with blunt Six anatomical dissections were performed on 3 fresh dissection. The buccopharyngeal fascia should be pre- cadaver heads to develop a reliable technique of flap har- served for 2 reasons: to prevent buccal fat pad herniation vest and to investigate the vascular territory of the main into the field of dissection and to avoid injury to branches posterior arterial feeder. The vascular supply was defined of the facial nerve. Small branches from the facial artery by contrast injection: 1 cadaver was injected with india ink may require ligation as may anterior venous tributaries from in the internal maxillary arteries and 2 were injected with the pterygoid plexus. The buccal artery, accompanying vein, latex in the carotid arteries and internal jugular veins. In- and buccal nerve arise laterally at the posteroinferior as- dia ink was injected into the distal internal maxillary ar- pect of the buccinator muscle. The pedicle may be iso- tery after ligating the branches between the point of injec- lated to create an island flap to facilitate rotation, but this tion and the buccal artery, thus allowing the ink to enter is not usually necessary. The flap is then transferred into only the buccal artery. A 10-mL syringe with an 18-gauge the defect and secured with long-lasting absorbable su- angiocatheter was inserted into the internal maxillary ar- tures, and the donor site is closed primarily (Figure 4 and tery and secured with a crimping silk suture, and the ink Figure 5).

sion was found to be superficially invasive, measuring 2 Tumor Stage and Site cm in diameter. This tumor was excised by an intraoral approach with 1-cm margins. A 3ϫ3-cm BMF was trans- Patient Age, y/ Tumor posed into the defect on the posterior neurovascular No. Sex Stage Tumor Site pedicle, and the donor site was closed primarily. 1 65/M T1 N0 Retromolar trigone The patient was discharged on postoperative day 1 2 62/M T1 N0 Soft palate and tonsillar pillar on a soft solid diet. Light touch perception was demon- 3 67/M T2 N0 Retromolar trigone 4 58/F T2 N0 Floor of mouth strated over the flap at the 1-week clinic follow-up. He 5 71/M T1 N0 Retromolar trigone was free of disease 9 months later with no postoperative 6 68/M T1 N0 Retromolar trigone sequelae. 7 77/M T1 N0 Soft palate 8 62/M T1 N0 Retromolar trigone RESULTS

Eight patients underwent primary tumor excision of soft palate, retromolar trigone, or floor of mouth lesions with the defect closed using the BMF. There were no tumor recurrences and no problems with mastication, oral con- p tinence, or facial nerve function. All patients demonstrated touch perception over their flap 2 weeks after sur- ∗ gery. This was evaluated by light touch with a tongue depressor over the mucosa of the transposed flap. There was 1 partial flap necrosis (the distal 3 mm in case 1) that was allowed to heal secondarily without sequelae. t The basic anatomy of this area has been described by Hollinshead1 and others.2-4 Through our cadaver dissections, we were able to outline the limits of the vascu- Figure 1. Intraoral view of a left retromolar trigone lesion. P indicates palate; lar territory of the buccal artery, investigate the incor- t, tongue; and asterisk, retromolar trigone tumor. poration of the buccal nerve with the flap, and define the

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b b

t Figure 2. Tumor removed and the buccinator musculomucosal flap (b) Figure 5. Reconstruction site 6 months after surgery. P indicates palate; b, outlined. P indicates palate; t, tongue. buccinator musculomucosal flap; and t, tongue.

p p

b d

d t

Figure 3. Buccinator musculomucosal flap (b) raised. P indicates palate; d, Figure 6. Right transoral view of a cadaver dissection; india ink injection was donor site; and t, tongue. used. M indicates maxilla; p, palate; and d, donor site.

pterygoid plexus posteriorly and from facial vein tributaries anteriorly.

COMMENT p We investigated the use of the posteriorly based BMF and d b found that it is a reliable, easily harvested local flap, useful for reconstruction of lesions involving the floor of mouth, retromolar trigone, and soft palate. It obviates the need for an intraoral bolster or harvesting of tissue be- t yond the oral cavity. Our cadaveric studies demonstrated the consistent isolation of the buccal artery, and the india ink injections demonstrated the generous blood Figure 4. Buccinator musculomucosal flap (b) inset into defect and the supply from this artery to the overlying cheek mucosa. donor site (d) closed primarily. P indicates palate; t, tongue. The buccal nerve is adjacent to the buccal artery and is easily included with the flap to maintain sensation to the amount of tissue that could be harvested. The buccal ar- overlying mucosa. The BMF was raised within 30 min- tery, a branch of the internal maxillary artery, originates utes without the use of magnification in all cases, mini- near the lateral aspect of the lateral pterygoid muscle en- mizing total intraoperative time. tering the posterior aspect of the buccinator muscle. This There was only 1 partial flap failure (case 1) in a pa- was demonstrated clearly with both latex and india ink tient with a prior resection in the same area as well as injections, the latter resulting in extensive staining of the prior radiation therapy; however, it was inconsequen- mucosa over the buccinator muscle as well as the mu- tial and was treated conservatively. While this flap can cosa of the superior alveolar ridge and lateral soft palate be used in previously irradiated fields, the risk of partial (Figure 6). The buccal nerve, a branch of the mandibu- loss may be higher. In addition, external carotid artery lar nerve, travels with this artery (Figure 7 and resection or thrombosis may also jeopardize the viabil- Figure 8). The buccal nerve provides sensory innerva- ity of this flap. All the donor sites were closed primarily tion to the mucosa of the cheek. A rich venous drainage leaving no raw surfaces, and there were no adverse ef- system is composed of the internal maxillary vein and fects secondary to harvesting the muscle, particularly with

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 erature, we believe that this flap is adequately supplied from either source alone. We noted that the vascular anatomy seen in both our cadaveric and surgical patients agrees with descrip-

Stensen Duct tions presented in prior studies. However, the proxim- ity of the buccal nerve to the buccal artery and its incorporation into the flap has been neglected. Our patients, when tested over the area of reconstruction in the early Buccal Mucosa postoperative period, reported fine-touch perception, and Buccinator Muscle this may aid in oral rehabilitation. The BMF has several advantages over other Buccinator Nerve options that have been used in the reconstruction of Buccal Artery oral cavity defects. Healing by secondary intention Tongue may risk contracture at the site with possible soft palate dysfunction. Skin grafts may not adhere to exposed bone and involve placement of a bolster that may be technically difficult in this area. Tongue flaps usually require 2 stages, and speech and swallowing may be adversely affected.9 The nasolabial flap requires an external excision and may not reach the retromolar tri- Figure 7. Line drawing of buccinator musculomucosal flap anatomy. gone. Regional flaps, such as the temporalis muscle flap, or free flaps such as the radial forearm, involve extensive extraoral dissection and are better reserved for larger defects. m The anatomy of the BMF is reliable and consistent. It provides similarly textured sensate tissue for recon- s struction in the oral cavity. It can be harvested quickly a n without morbidity, and the donor site can be closed primarily with excellent cosmesis and function. A signifi-

d cant advantage is the inclusion of the buccal nerve with b the vascular pedicle, allowing the flap to be sensate. This t versatile local flap should be considered for reconstruction of defects of the floor of mouth, retromolar trigone, and soft palate.

Accepted for publication June 27, 1997. Figure 8. Cadaver dissection, transoral view, with a right buccinator musculomucosal flap (b) raised on a pedicle. S indicates Stensen duct; m, Corresponding author: Greg R. Licameli, MD, Depart- maxilla; a, buccal artery; n, buccal nerve; d, donor site; and t, tongue. ment of Otolaryngology–Head and Neck Surgery, Univer- sity of Illinois at Chicago, 1855 W Taylor St, Chicago, IL 60612.

respect to mastication, oral continence, or facial nerve REFERENCES dysfunction. Buccal mucosa was first used to repair septal per- forations and palatal fistulas.5,6 As experience was gained 1. Hollinshead WH. Anatomy for Surgeons: The Head and Neck. 3rd ed. Philadel- phia, Pa: JB Lippincott Co; 1982. with the use of local random buccal mucosa flaps for clo- 2. Bozola RA, Gasques JAL, Carriquiry CE, deOliveira MC. The buccinator muscu- sure of intraoral defects, the incorporation of the under- lomucosal flap: anatomic study and clinical application. Plast Reconstr Surg. 1989; lying buccinator muscle was described. Sasaki et al7 out- 84:250-257. lined the use of a cheek island flap for reconstruction of 3. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: facial artery mus- cervical esophageal strictures that was based on the fa- culomucosal (famm) flap. Plast Reconstr Surg. 1992;90:421-429. 8 4. Carstens MH, Stofman GM, Hurwitz DJ, Futrell JW, Patterson GT, Sotereanos cial artery and vein. Subsequently, Maeda et al de- GC. The buccinator myomucosal island pedicle flap: anatomic study and case scribed posteriorly based cheek mucosal flaps for length- report. Plast Reconstr Surg. 1991;88:39-50. ening of the palate. The anatomical basis for this flap was 5. Filiberti AT. Plastic closure of a septal perforation. Ann Chir Otorhinolaryngol. illustrated by Bozola et al,2 who used it for palatal clefts 1965;96:1-7. 6. Jackson IT. Closure of secondary palatal fistulae with intraoral tissue and bone and for 1 case of palatal carcinoma. They noted that the grafting. Br J Plast Surg. 1972;25:93-97. main blood supply to the flap was based posteriorly on 7. Sasaki TM, Baker HW, McConnell DB, Yeager RA, Vetto RM. Cheek island flap the buccal artery; however, no attempt was made to iso- for replacement of critical limited defects of the upper aerodigestive tract. Am J late the pedicle and island the flap. Carstens et al4 have Surg. 1986;152:435-437. reported that the dominant blood supply is anterior from 8. Maeda K, Ojimi H, Utsugi R, Ando S. A t-shaped musculomucosal buccal flap for cleft palate surgery. Plast Reconstr Surg. 1987;79:888-895. the facial artery. All flaps used in our series were sup- 9. Sessions DG, Cummings CW, Weymuller EA, Makielski KH, Wood P. Atlas of plied posteriorly as harvested; however, based on our clini- Access and Reconstruction in Head and Neck Surgery. St Louis, Mo: Mosby– cal observations, cadaveric studies, and review of the lit- Year Book Inc; 1991:254-260.

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