British Journal of Plastic Surgery (2005) 58, 10611066

Reconstruction of intraoral defects using facial artery musculomucosal ap

A. Joshi, J.S. Rajendraprasad, K. Shetty*
Plastic, Reconstructive and Microvascular Services, Tata Memorial Cancer Center and Hospital, Parel, Mumbai 400012, India
Received 17 August 2004; accepted 29 April 2005

KEYWORDS
Intraoral; Postexcision defects; Facial artery; Musculomucosal ap

Summary The facial artery musculomucosal ap, technically a combination of the nasolabial ap and the buccal mucosal ap, has been a reliable, versatile ap, either superiorly or inferiorly based for reconstruction of a wide variety of postcancer excision intraoral mucosal defects including defects of the palate, alveolus, lips and oor of mouth. We have used it 17 times in 16 patients with no failures and one ap with terminal necrosis. Almost all aps developed venous congestion which settled on its own by conservative management. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.

Resurfacing of oral lining defects using like tissue is always preferable since regional aps lack similar tissue characteristics, may interfere with oral competence and involve lengthy procedures. Use of local intraoral aps when suitable is a very useful option. We found the facial artery musculomucosal (FAMM) Flap, rst described by Pribaz et al.1 in 1991, a very useful axial ap to cover moderate size intraoral defects of the alveolus, oor of mouth, cheek, lip and palate. Though the most common indication for the original use of the ap has been for closure of palatal clefts and stulae,1,2 we have used it for closure of defects resulting after cancer excision.

* Corresponding author. Tel.: C91 22 24177197. E-mail address: plasticsurgerytmh@hotmail.com (K. Shetty).

Figure 1

Flap marking.

S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.04.052

1062

A. Joshi et al.
Table 1 Distribution of cases according to defect site and ap base Defect site Alveolus Lip Floor of mouth Lip with oor of mouth Full thickness lip (with nasolabial ap) Palate Total No. of patients 5 4 4 1 1 2 17 Flap base Inferior Inferior Inferior Inferior Inferior Superior

Figure 2

FAMM ap harvested (superiorly based).

Surgical anatomy
The FAMM ap is more an arterialised ap than an axial pattern ap based on the facial artery.3 It combines the principles of nasolabial and buccal

mucosal aps. It consists of mucosa, submucosa, a small part of buccinator, deeper plane of orbicularis oris, facial artery and venous plexus. The ap can be superiorly or inferiorly (posteriorly)4 based depending on its vascularity and the defect to be covered. Superiorly based FAMM ap can be used to cover the defects in the hard palate, alveolus, nasal lining, upper lip and sometimes even the orbit.

Figure 3 (AD). Case no. 1. A superiorly based FAMM ap has been used for postablative palatal stula following excision of a nasopharyngeal adenocarcinoma. The nasal layer was closed using turned down mucosal aps followed by a superiorly pedicled FAMM ap which was divided after 3 weeks.

Reconstruction of intraoral defects using facial artery musculomucosal ap

1063

Figure 4 (AD). Case no. 2. An inferiorly based FAMM ap has been used for reconstructing lower lip sulcus. The ap being less bulky with like tissue, tting of dentures becomes very easy as seen in the postoperative pictures.

The inferiorly based FAMM ap can be used for defects in the alveolus, oor of mouth, lower lip and vermillion5 and tonsillar fossa. Extensive use of this ap for postablation maxillofacial defects has been seen of late.6 An inferiorly based FAMM ap can be used only if the facial artery and if possible the linguofacial vein have been preserved in neck dissections. In case where the vein has been ligated, venous drainage can still be ensured by preserving wide soft tissue at the base.

(Fig. 2). The rest of the ap is then incised including a part of the deep layer of the orbicularis oris muscle. The base of the ap may then be islanded provided enough soft tissue is retained for adequate venous drainage. The donor defect can be closed primarily in two layers, muscle and mucosa, taking care to avoid the Stensons duct opening or may be covered with a split thickness skin graft (Figs. 36).

Surgical technique
The ap is centred on the facial artery, oriented obliquely extending from the retro molar trigone to the upper gingivolabial sulcus at the alar margin (Fig. 1). The maximum width of the ap can be 1.52 cm, well anterior to the Stensons duct. An incision is rst made distally through the mucosa and buccinator, the facial artery is identied, ligated and cut according to the base of the ap

Material and method

From January 2001 to December 2003, a total of 17 FAMM aps have been used in 16 patients (in one of the patients we have used bilateral inferiorly based FAMM aps for a large defect in the oor of the mouth). The patient range has been from 12 to 70 years. The distribution of the cases according to the defect site and ap base has been as follows (Table 1).

1064

A. Joshi et al.

Figure 5 (AF). Case no. 3. An inferiorly based islanded FAMM ap has been used for reconstructing the defect over the middle third mandibular alveolus and lower lip mucosa.

Results and discussion

The most common indication for the FAMM ap has been for the alveolus and the oor of mouth defects. Only two aps used for the hard palate were superiorly based, the rest all were inferiorly based. All the aps were islanded except those for the palate, which were pedicled. It was necessary to use bite blocks in these two cases to prevent

biting of the pedicle. Almost all aps developed varying degrees of venous congestion immediately postoperatively within 46 h, which settled on its own by conservative management after 2448 h. One ap developed terminal marginal necrosis for reasons that are not clear, which needed minimal debridement of the necrotic part of the ap following which the intraoral raw area healed by granulation and subsequent mucosalisation. This

Reconstruction of intraoral defects using facial artery musculomucosal ap

1065

Figure 6 (AD). Case no. 4. An example of full thickness palatal defect following excision of an adenocarcinoma where we used a posteriorly based tongue ap to form the nasal lining over which a superiorly based FAMM ap was used to form the oral lining. The late postoperative picture shows very well settled aps with excellent palatal contour obtained.

was an inferiorly based FAMM ap used for reconstruction of the oor of mouth following wide excision of squamous carcinoma. In one of the cases of squamous carcinoma of the lower lip, we have used an inferiorly based FAMM ap for reconstructing the mucosa and the vermillion in combination with an opposite sided islanded nasolabial ap for the skin defect. The FAMM ap was minimally congested for rst 3 days and then gradually settled completely without ap loss. In another case of squamous carcinoma of the middle third of the alveolus of the mandible, we have used an inferiorly based FAMM ap to cover the silastic implant used as a spacer after middle third mandibulectomy and the lip mucosal defect. The ap settled well after initial congestion but the silastic implant later needed removal in the second postoperative week because of infection. The maximum ap dimensions in our series were 8!3 cm2. Care was taken to ensure that the ap remained axial, the long axis strictly maintained over the facial artery. It was possible to obtain primary closure of the donor site in all the cases.

There was some cheek oedema and tightness at the donor site that resolved without any long-term morbidity. To summarise, we have found that the FAMM ap has been a reliable, versatile and a very useful axial ap for postcancer excision intraoral defects and denitely preferred to skin aps since it provides like tissue which is hairless and less bulky, thus helps to give good competence and makes tting of dentures and mastication very easy. Its only disadvantage is initial venous congestion and that it is not suitable for covering large intraoral defects. An important prerequisite is that the facial artery needs to be necessarily preserved if a neck dissection is warranted.

References
1. Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral ap: facial artery musculomucosal (FAMM) ap. Plast Reconstr Surg 1992;90:4219. 2. Fassio E, Laure B, Durand JL, Bonin B, Aboumoussa J,

1066
Ballon G, et al. The facial artery-buccinator musculo-mucosal ap for reconstruction of the palate. Rev Stomatol Chir Maxillofac 1999;100:2215. 3. Dupoirieux L, Plane L, Gard C, Penneau M. Anatomical basis and results of the facial artery musculomucosal ap for oral reconstruction. Br J Oral Maxillofac Surg 1999;37:258. 4. Zhao Z, Li S, Yan Y, Yang M, Mu L, Huang W, et al. New buccinator myomucosal island ap: anatomic study and clinical application. Plast Reconstr Surg 1999;104:5564.

A. Joshi et al.
5. Pribaz J, Meara G, Wright S, Smith J, Stephens W, Breuing K. Lip and vermillion reconstruction with the facial artery musculomucosal ap. Plast Reconstr Surg 2000;105:86472. 6. Anastassov GE, Schwartz S, Rodriguez E. Buccinator myomucosal island ap for postablative maxillofacial reconstructions: a report of 4 cases. J Oral Maxillofac Surg 2002;60: 81621.