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The buccinator-based myomucosal flaps are axial pattern flaps that are suitable in reconstruction of medium sized oral soft tissue defects; they are rich in blood supply, have appropriate thickness and considerable mucosal paddle, and they can secrete saliva. The present study describes surgical anatomy and blood supply of these flaps and demonstrates all possible modifications of these flaps 9 modifications.
This report introduces a new classification system mainly based on the remaining attachments of buccinator muscle after flap elevation in pedicle variants and axial blood supply orientation in island variants. Reconstruction of intraoral soft tissue defects from traumatic injuries, treatment of pathologic lesions, or congenital wide palatal clefts are interesting. Replacement of resected or defective mucosa with appropriate tissue has concerned surgeons for long.
Special kind of fasciocutaneous, myocutaneous, and muscle flaps for coverage of intraoral soft tissue defects have been designed. Pediculated mucosal flaps such as palatal rotation flaps, myomucosal tongue, and labial flaps can provide mucosa for soft tissue defects that cannot be managed by direct closure, secondary epithelialization, or free mucosal grafting. Buccinator-based myomucosal flaps are rich in blood supply, have appropriate thickness and considerable mucosal paddle,[ 8 ] and they can secrete saliva; hence, they are good choices for the repair of intraoral medium sized mucosal defects.
Buccinator muscle originates posteriorly from pterygomandibular raphe and blend with orbicularis oris muscle anteriorly. Maxillary vestibule is its upper limit, and mandibular vestibule and external oblique ridges are lower limits. Oral mucosa covers intraoral side and, in external surface, it is adjacent to the facial artery and vein, buccal fat pad, and buccopharyngeal fascia. Nervous network from facial nerve buccal plexus is responsible for motor innervation. Sensory inputs are collected by buccal nerve, which is a branch of mandibular nerve, and enters the buccinator muscle via the posterior border.
Some buccal lymph nodes and minor salivary glands also present in this region. Stensen duct penetrates the muscle and enters oral cavity slightly above the center of the muscle. Facial artery and vein run obliquely from posterior-inferior part of buccinator muscle and run anteriorly toward nose in the oblique direction.
Posterior superior alveolar PSA artery and vein enter it in the most posterior-superior corner and distribute over the buccinator muscle. This artery communicates with infraorbital artery branches. Buccal artery enters the posterior border of the muscle in junction with superior constrictor pharyngeal muscle; it accompanies buccal nerve. Rich venous plexus over buccinator muscle drain into facial vein or pterygoid plexus. All these vessels anastomosed with each other extensively [ Figure 1 ].
Schematic blood supply of buccinator-based myomucosal flaps. Facial artery and its branches Ab, Ib, Pb , buccal artery, and nerve. Note anastomosis between Pb and buccal artery. Superior limit of most buccinator myomucosal flaps are under stensen duct opening, so these flaps are partial buccinator flaps.
The patient was a year-old girl with benign pathologic lesion that involved soft palate. Posteriorly based buccinator myomucosal pedicle flap reconstructed the mucosal defect, immediately after resection [ Figure 2 ]. This flap relays on buccal artery a branch of maxillary artery for survival. Long buccal nerve accompanies this artery, therefore, it is neurovascular pedicle flap and sensory return is predictable.
There was no need for pedicle base division. Donor site closed primarily. The patient was a year-old man with melanoma of anterior maxilla. Under general anesthesia, wide surgical resection, and supraomohyoid neck dissection SOHND in the right side was done. Bilateral superiorly based buccinator myomucosal pedicle flap was used for reconstruction [ Figure 3 ]. The patient received postoperative radiotherapy.
The patient was a year-old male patient with large oronasal fistula from surgical resection and radiotherapy of nasal cavity angiofibroma, 10 years ago. Clinical picture was very similar to that of wide adult palatal cleft. Voice changes and difficulty in eating were the two main chief complaint of the patient. In delayed reconstruction 10 years after the first operation, the fistula closed with superiorly based buccinator island flap.
Donor site was closed with inferiorly based masseter muscle flap effectively [ Figure 4 ]. Buccal fat pad could not herniate in surgical field for donor site coverage, probably because of previous radiotherapy, thus masseter muscle flap became the choice. The patient was a year-old edentulous male with mandibular ramus and angle ameloblastoma with perforation of soft tissue lingual to the ridge. Bony segmental resection with the removal of overlying involved mucosa was done.
Intraoral incisions were used for tumor resection. Inferiorly based buccinator myomucosal pedicle flap was used for reconstruction. There was no need for pedicle division [ Figure 5 ]. The patient was a year-old female with squamous cell carcinoma of right lateral border of tongue T3-N0-M0. Wide resection with safety margins was done. SOHND in the right side of the neck accompanied with preservation of facial vein and artery. The patient was dentate in posterior region, therefore inferiorly based buccinator myomucosal island flap was used for reconstruction [ Figure 6 ].
The formed flap was turned around the inferior border of the mandible and brought to the lingual side to cover the raw surface of lateral tongue. Donor site managed with buccal fat pad mobilization that clinically epithelialized 3 weeks later. Glandular branches and submental artery are ligated, d Inferiorly based buccinator myomucosal islanded flap that contains facial artery and vein turned under mandibular border and brought medial to the mandible, e Reconstructed defect, f buccal fat pad transposition, g Schematic picture.
The patient was a year-old man with biopsy proven central giant cell granuloma of the mandible CGCG with bone perforation and soft tissue involvement. Defective mucosa after enucleation of the lesion made reconstructive procedures necessary.
Random pattern buccinator myomucosal flap without including the axial artery in base covered the defect, therefore, soft tissue dehiscence and the problem of exposed bone cavity was prevented. Donor site closed primarily [ Figure 7 ]. Random pattern buccinator myomucosal flap without including facial artery and vein is harvested, b Reconstructed defect, schematic picture.
The patient was a year-old man with lower lip squamous cell carcinoma stage II. The lesion resected with safety margins, and denuded lip was reconstructed with anteriorly based buccinator myomucosal flap.
The pedicle was 1 cm posterior to the oral commissural, and its width was 1. The flap contained facial artery [ Figure 8 ]. The patient was a 9-year-old boy with large peripheral giant cell granuloma in the mandibular alveolar ridge that extends from the right first permanent molar to the right canine area. After tumor removal, there was denuded area that was covered with posteriorly based buccinator island flap.
Buccal fat pad covered the donor site [ Figure 9 ]. PSA : Posterior superior alveolar artery. Buccinator-based myomucosal flaps are not suitable for large oral mucosal defect coverage. Stensen duct pierce buccinator muscle slightly above its center. Considering 0. Partial buccinator flap is useful term for these flaps. Relocation of stensen duct adds more mucosa. Larger donor sites always managed with buccal fat pad mobilization, which undergoes epithelialization.
Skin graft or masseter muscle flap are other options. In Table 1 , some pioneer surgeons in this field and the terms that they have introduced in this topic are listed. Some pioneer surgeons in buccinator-based myomucosal flaps and the terms that they introduced. Bozola, Carstens, and Pribaz—all noted that facial artery gives some branches to the buccinator muscle. Bozola believed that most blood supply of the buccinator muscle comes from the buccal artery.
Anteriorly based buccinator myomucosal flap was introduced by Carstens et al. Nowadays, anteriorly based buccinator myomucosal flap should be used just for buccinator flaps, in which the pedicle is near oral commissure and superior, posterior, and inferior margins are incised. Facial artery should be incorporated in flap base.
Flap pedicle can be between facial artery and vein or in between facial artery and oral commissure [ Figure 10 ]. Facial artery branches to buccinator muscle Ab are responsible for flap survival. Facial vein can be ligated to give the flap more mobility. Facial artery is incorporated in the base of the flap. Flap pedicle in between lip commissure and facial artery, b Flap pedicle in between facial artery and vein.
Zhao et al. Posterior buccal Pb that nourish posterior half of the buccinator muscle and anastomose the buccal artery. Inferior buccal branch Ib that nourish inferior part of the buccinator muscle [ Figure 1 ]. Buccinator-based myomucosal flaps that are axial pattern and are based on facial artery and vein can have superior, inferior, or anterior bases. Nutrient vessels can be skeletonized island flaps: Zhao modification and arterialized FAMMIF or considerable soft tissue surround the axial vessels pedicle flaps: FAMM flap and anteriorly based buccinator flap.
In Table 2 , new classifications of buccinator-based myomucosal flaps that are suggested by the authors are given. Posteriorly based pedicled buccinator flap are based on buccal artery a branch of maxillary artery ; therefore, their usage is not dependent on intact facial artery and vein. Incorporation of Ib inferior buccal branch makes its blood supply more predictable.
Posteriorly based island pedicled buccinator flap is a variant, in which the mucosa is incised circumferentially and mucosal paddle is separated from the adjacent mucosa, but the flap is attached to the underlying pedicle that supply it via the buccal artery. This modification will increase flap mobility.
The flap is islanded on a pedicle of the buccinator muscle. This concept comes from subcutaneous island pedicle skin flaps. Theoretical basis for superiorly based buccinator myomucosal flaps are based on anastomosis between facial artery and intracranial vessels via angular artery in the lateral side of the nose reverse flow or retrograde. In inferiorly based buccinator flaps, facial artery and vein should be preserved in neck dissections, so that this flap cannot be used in patients with positive nodes or previous neck dissection.
Buccinator-based myomucosal flaps in intraoral reconstruction: A review and new classification
Intraoral view of a left retromolar trigone lesion. P indicates palate; t, tongue; and asterisk, retromolar trigone tumor. Tumor removed and the buccinator musculomucosal flap b outlined. P indicates palate; t, tongue. Buccinator musculomucosal flap b raised. P indicates palate; d, donor site; and t, tongue. Buccinator musculomucosal flap b inset into defect and the donor site d closed primarily.
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Buccinator flap operation
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Use of a Versatile Buccinator Myomucosal Flap in the Palatal Defect