Accepted Manuscript Head and Neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap Silvano Ferrari , MD, Associate Professor, Andrea Ferri , MD, Bernardo Bianchi , MD, Enrico Contadini , MD, resident, Massimiliano Leporati , MD, Enrico Sesenna , MD, full professor, chief PII:
S0278-2391(14)01792-3
DOI:
10.1016/j.joms.2014.11.017
Reference:
YJOMS 56575
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 2 October 2014 Revised Date:
15 November 2014
Accepted Date: 17 November 2014
Please cite this article as: Ferrari S, Ferri A, Bianchi B, Contadini E, Leporati M, Sesenna E, Head and Neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2014.11.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Head and Neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap.
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Ferrari S, Ferri A, Bianchi B, Contadini E, Leporati M, Sesenna E
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Silvano FERRARI, MD, Associate Professor; Andrea FERRI, MD; Bernardo BIANCHI, MD; Enrico CONTADINI, MD, resident; Massimiliano LEPORATI, MD; Enrico
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SESENNA, MD, full professor, chief.
Maxillo-Facial Surgery Division (Head: Professor Enrico Sesenna); Head and Neck
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Department; University Hospital of Parma.
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Corresponding author: Andrea Ferri. Address: via Gramsci 14; 43100 Parma; Italia. Telphone: +390521703107; +390521703109. Fax: +390521703761.
e-mail: [email protected]
ACCEPTED MANUSCRIPT Head and Neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap.
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Abstract
Purpose. Myomucosal buccinator flaps use in the reconstruction of oral cavity defects is well established in the international literature, however their use for the
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reconstruction of defects not located in the oral cavity has been largely underestimated. Purpose of the study is to describe and review the applications of
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superiorly based facial artery myomucosal flap in the head and neck reconstruction.
Methods. Retrospective evaluation of twelve patients underwent reconstruction of palate, lip, nasal septum and conjunctiva with reverse-flow FAMM flap Mouth
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opening, speech, reconstruction effectiveness and esthetic outcomes were analyzed.
Results. The patient cohort consisted of 7 males and 5 females, aged between 33
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and 80 years (mean 56.2). No major complication occurred. Cosmetic results were excellent in the largest part of the patient. Functionally, the best results were
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obtained in palate, lip and conjunctiva reconstruction. Nasal reconstruction led to mild air-way obstruction in 2 cases and severe obstruction in the other one. Conclusion. The superiorly based FAMM flap plays an important role in the reconstruction of particular defects involving the oral cavity and other distant sites of the head-and-neck area. Its reliability, low morbidity and the optimal results that can be achieved using this technique make this flap a good option for such reconstructions.
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Each author disclose any commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in any
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submitted manuscript.
ACCEPTED MANUSCRIPT Introduction Buccinator myomucosal flaps are well described in the international literature1. Owing to the very low morbidity related to their harvesting2, the possibility of
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reconstructing mucosal defects with tissue having the same features as the resected tissue, and to their reliability, these flaps are presently widely used worldwide3. Some recent reviews have indicated that the main indication of these
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flaps is reconstruction of oral cavity defects, including defects of the floor of the mouth, tongue, soft and hard palate, and oropharynx4. Conversely, the use of
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buccinators flaps, particularly facial artery myomucosal flaps (FAMM flaps), for the reconstruction of defects not located in the oral cavity has been largely underestimated in international publications. The superiorly based facial artery myomucosal flap is a variation of the FAMM flap first described by Zhao et al. in
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19995. This flap is based on the retrograde flow provided by the facial artery; the pivot point is located in the upper vestibula, ensuring a wide arch of rotation that allows reconstruction of “upper-located” defects, including the anterior portion of
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the hard palate, nasal septum, skull base, and conjunctiva. Few papers focusing on this flap have been published, each of which has emphasized reconstruction of a
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specific site. However, a comprehensive review of the clinical application of this flap is lacking in the English-language literature. The purpose of this paper was to analyze the authors’ experience with the superiorly based FAMM flap, focusing on its indications, advantages, and limits, in head-and-neck reconstruction.
Surgical technique
ACCEPTED MANUSCRIPT Harvesting of the flap starts with forced mouth opening and identification of the facial artery pattern using a portable Doppler probe. Once the facial artery has been identified, the flap is designed including the artery, taking care to preserve
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Stensen’s duct: the flap is usually a fusiform or “shuttle” shape. The first incision is carried out in the anterior and inferior aspects of the flap: the buccinator muscle is identified, and dissection proceeds in a blunt fashion through the fat tissue
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underlining the buccinator, where the facial artery arising from the mandibular area is identified, ligated, and cut. The medial and lateral margins of the flap are
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incised, and the flap is elevated, including the facial artery, which can be followed up to the superior buccal sulcus where the flap is based. Depending on the need for reconstruction, the superior incision can be extended up to the canine, if the nasal cavity needs to be reached; if the conjunctiva has to be reconstructed, dissection of
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the flap’s pedicle proceeds up the nasal base to increase its arch of rotation. Once the flap has reached its recipient site, reconstruction is completed, and the donor site is closed primarily; otherwise, in the case of large flap harvesting, the buccal
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fat pad is advanced.
Patients
To address the research purpose a retrospective evaluation of patients underwent reconstruction using a superiorly based FAMM flap between January 1, 2000 to December 31, 2013 was conducted. Owing to the retrospective nature of the study, exemption from institutional review board approval was granted by our institution. The manuscript was written in compliance with the Declaration of
ACCEPTED MANUSCRIPT Helsinki. Patients were evaluated concerning complications, donor site morbidity, cosmesis and functional outcome related to the reconstructed site. Donor site morbidity was evaluated to assess the mouth opening (limited, partially
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limited or normal), damage to the facial nerve branches (permanent palsy, temporary palsy or none) and speech (unintelligible, partially intelligible or normal). Cosmesis was assessed by the patient as poor, acceptable, good or
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excellent. Functional evaluation differed from site to site: palatal fistula resolution of oro-nasal communication was assessed as absent (same condition before
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surgery), incomplete (partial resolution of symptoms with liquid reflux and air communication), or complete (return to normal condition). Upper lip reconstruction was functionally evaluated concerning oral competence (poor, acceptable, or normal). Functional evaluation of nasal reconstruction concerned
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closure of perforation or defect (incomplete or complete) and nasal obstruction (severe, partial, or none). Finally, the patient who underwent reconstruction of the conjunctiva was evaluated for ocular impairments that were assessed as severe
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(pain, visual deficits, severe keratitis, or corneal ulceration), mild (lagophthalmos,
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mild keratitis, or mild pain), absent (restoration of normal ocular function).
Results
The patient sample consisted of 12 patients among 85 undergoing reconstruction of head-and-neck defects using buccinator myomucosal flaps. The patient cohort consisted of 7 males and 5 females, aged between 33 and 80 years (mean 56.2). Data are summarized in Table 1. The defect site included the anterior hard palate in 6 patients affected by palate fistula, upper lip in 2 patients
ACCEPTED MANUSCRIPT with previously treated squamous cell carcinoma or rhabdomyosarcoma of the vermillion, nasal septum in 2 patients with septum perforation, lateral nasal wall in 1 patient with nasal mucosa carcinoma, and inferior conjunctiva in one patient
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treated for an infra-orbital cutaneous basal cell carcinoma. Forced mouth opening was applied during the first post-operative week in 5 patients underwent anterior palate reconstruction. Resection of the vascular
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pedicle was required in 5 patients and was performed under local anesthesia between 20 and 45 days after the first surgery. In 2 patients treated for nasal
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septum reconstruction, a secondary revision surgery was required to reduce the bulk of the flap that caused nasal obstruction.
All of the flaps were harvested and transposed successfully. No major complication occurred. Minor complications included dehiscence of the palatal wound in 2
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patients, dehiscence of the donor site suture in 1 case, venous congestion in 2 cases that underwent spontaneous resolution after 4–6 days, partial necrosis of 1 flap used for palatal fistula closure that was treated with debridement and suture
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replacement without interference with patient outcome. Donor site morbidity evaluation revealed, as expected, optimal outcomes with no
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cases of mouth opening severe limitation or permanent facial nerve damage, and normal speech and diet in most patients. The largest majority of subjects showed excellent cosmetic results. Functionally, the superiorly based FAMM flap was very effective for oro-nasal fistula treatment, with complete resolution in all patients. Additionally, the analysis of the upper lip reconstruction revealed good results, especially considering that both these patients were previously treated with surgery and radiation therapy for their malignancies. Reconstruction of the nasal
ACCEPTED MANUSCRIPT mucosa led to optimal results when closure of the defect was considered, while nasal function evaluation revealed partial obstruction in most patients and severe obstruction in one. Finally, the patient who underwent conjunctiva reconstruction
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showed an acceptable outcome with lagophthalmos and the requirement for ocular ointment; however, scarring on the periocular complex related to major surgery strongly biased this evaluation and caused difficulty regarding
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understanding the outcome related to conjunctiva reconstruction alone.
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Discussion
At present, the major role played by myomucosal buccinator flaps in the reconstruction of oral cavity defects is well established in the international literature6. The use of these flaps has reduced the indication for free flap
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reconstruction, thus improving functional and esthetic results and simultaneously tremendously reducing morbidity for the patient7. The selection of the buccinator flap to use, based on the defect site, neck treatment, dentition and facial vessel
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availability represents one of the key points in such reconstructions. The purpose of the paper is to review the indications for the use of the reverse flow FAMM flap.
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The superiorly based/reversed-flow FAMM flap differs from other buccinator flaps not only regarding the pivot of the pedicle, but also because of its particular perfusion pattern. Arterial vascularization is provided by a retrograde flow that arises from the angular branch of the facial artery and that receives some adjunctive flow from the infra-orbitary and skull base branches. Despite this retrograde flow, several authors have confirmed its reliability, even if venous drainage is provided only by the submucosal plexus and not by preservation of the
ACCEPTED MANUSCRIPT facial vein8. Some others advocate for caution when performing reverse-flow FAMM flap because of possible vascular anomalies and a steep learning curve; however, in our series no difficulties were encountered.
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The peculiar position of the pedicle’s pivot allows a unique arch of rotation that is extremely useful when the upper and distant sites, such as the anterior hard palate, upper lip, nose, skull base and conjunctiva, need to be reached. At each of these
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sites, this flap provides peculiar advantages that enable its use as a first-line treatment in the reconstruction of defects involving these areas.
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When defects of the anterior hard palate are approached, the use of reverse FAMM flaps offers several advantages. The superior position of the pedicle pivot ensures the possibility to also reach the most anterior palatal area without interference with the patient’s dentition; therefore, teeth removal is required very rarely9.
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However, we usually prefer a forced mouth opening during the first week after surgery to avoid accidental flap damage during biting, rather than to prevent trismus, as we did in 5 patients of the series here reported. The pedicle section is
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not always required; however, we found that patient who underwent this procedure benefited in terms of mouth opening and oral comfort. Compared with
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other buccinator flaps10, 11, the superiorly based is the only one that can easily reach the most anterior part of the hard palate, particularly in dentate patients: an inferiorly based flap’s pedicle is too far from the recipient site, with a high risk of flap damage or detachment; a posteriorly based flap cannot reach the anterior hard palate; and island flaps require a more complex technique without a great increase in the flap’s arch of rotation. Our results confirm the reliability of
ACCEPTED MANUSCRIPT myomucosal buccinator flaps when anterior palatal fistulas or clefts are approached using this technique. (Figures 1, 2, 3). Upper lip reconstruction represents a real challenge in many patients who
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undergo lip resections or are affected by lip defects after traumas: for defects involving less than one-third of the lip, the use of the inferior one as a donor site likely ensures the most reliable and cosmetic results. However, when total or
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subtotal upper lip defects are approached, the superiorly based FAMM ensures a large amount of mucosa availability, thus allowing safe and precise reconstruction
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of the lip12. The morbidity is very low, post-operative forced mouth opening is often unnecessary in these patients and required only when there is risk for pedicle biting. We usually perform pedicle resection after 3 weeks to optimize the oral vestibular shape and release the lip, thus improving mouth opening. As in the
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patient presented here, the mucosa of the flap usually undergoes spontaneous reepithelialization, which ensures optimal results in terms of cosmesis. The possibility of the reconstruction of sites far from the oral cavity represents the
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most critical feature of the reversed-flow FAMM flap. If vestibular dissection proceeds up to the canine, it is easy to rotate the flap into the nasal cavity, thus
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facilitating the reconstruction of several defects. Nasal septum perforation, independently from its origin, represents one of these defects13. When other nasal flaps are not available, or the perforation is too extensive for intra-nasal local flap reconstruction, the large amount of healthy mucosa provided by the superiorly based FAMM flap represents an ideal solution14. In these cases, the most critical point is the insetting of the flap: in our experience, a closed or endoscopic approach was fairly utopian, and “open rhinoplasty” access was preferable. Thus,
ACCEPTED MANUSCRIPT we could control the flap insetting and perform sutures that represented probably the most difficult part of the procedure, particularly in the posterior area of the septum. We avoided lateral rhinotomy access for septum defects to avoid scars and
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retraction, thus ensuring optimal cosmesis; however, this certainly represents an option, as advocated by other authors. During flap transposition, the anterior nasal spine is usually exposed to an increased space for flap transfer; however, widening
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by drilling is usually unnecessary. To maximize the arch of rotation, dissection of the oral vestibulum up to the canine area is mandatory and ensures safe and easy
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rotation into the oral cavity and the possibility to orientate the flap with the mucosal aspect in the correct position for lining reconstruction. (Figures 4, 5, 6). Excessive bulk, particularly in males, in whom the buccinator muscle is more represented, is the most critical issue. We needed to revise 1 flap with submucosal
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debridement to improve air flow: the procedure was straightforward and yielded satisfactory results; however, real improvements were usually observed only after 6–12 months, likely because of atrophy of the buccinator muscular component of
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the flap.
The same principles of nasal septum reconstruction were employed for lateral
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nasal wall reconstruction for malignancies. In those cases, lateral rhinotomy represents the ideal approach to achieving adequate field exposure for safe control of malignant tumor margins. Once in the nose, the path to the skull base is short: we did not use the superiorly based/reversed-flow FAMM flap for skull base reconstruction; however, some authors have described its harvesting and transposition in specimens15, while others have confirmed the possibility of its application in anterior fossa base
ACCEPTED MANUSCRIPT reconstruction16. Indeed, the pedicle length allows the skull base to be reached, and the flap has adequate bulk and mucosa for skull base reconstruction. However, using an endoscopic approach, the achievement of a safe suture and suspension
application of the reversed-flow FAMM flap.
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seems quite difficult, and further studies are needed to confirm this particular
The final, and probably the most fascinating, application of this flap is the
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reconstruction of conjunctiva5. This area represents a major challenge for the reconstructive surgeon, particularly because more extensive resections are often
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required simultaneously. The importance of conjunctiva reconstruction when the inferior lid is resected and the eye is spared is obvious. The mucosa provided by the reversed-flow FAMM flap ensures eye protection and avoids scar retraction with corneal exposure. Furthermore, it allows eye moisture preservation, thus
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increasing the patient’s comfort and eye protection. For conjunctiva reconstruction, accurate pedicle dissection is mandatory to achieve an adequate length to reach the eye; however, simultaneous resection of cheek soft tissues that is usually
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performed for such types of malignancies (as in the patient here presented), makes the dissection and flap transposition more confortable for the surgeon (Figures 7-
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11). Additionally, in these cases, the “time factor” plays a mayor role: debridement of excessive bulk is difficult, and we noticed in our case that, although initially evident, the excess bulk underwent spontaneous regression within 18 months, allowing for satisfactory results, particularly considering the structures resected with the tumor.
Conclusion.
ACCEPTED MANUSCRIPT Of the buccinator myomucosal flaps, the superiorly based / reverse flow FAMM flap plays an important role in the reconstruction of particular defects involving the oral cavity and other distant sites of the head-and-neck area. It is the only
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buccinator flap that can function also as a “loco-regional” flap when employed in nasal, skull base, and conjunctiva reconstruction. Its reliability, low morbidity and the optimal results that can be achieved using this technique make this flap a good
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solution for such reconstructions.
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Conflict of interest: none.
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Funding to disclose: none.
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The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see:
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http://www.textcheck.com/certificate/6awpPe
ACCEPTED MANUSCRIPT References. 1. Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Myomucosal cheek flaps: applications in intraoral reconstruction using three different techniques.
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Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 108:353-9. 2. Ferrari S, Ferri A, Bianchi B, Copelli C, Boni P, Sesenna E. Donor site
morbidity using the buccinator myomucosal island flap. Oral Surg Oral Med
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Oral Pathol Oral Radiol Endod. 2011; 111:306-11.
3. Massarelli O, Baj A, Gobbi R, Soma D, Marelli S, De Riu G, Tullio A, Giannì AB.
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Cheek mucosa: a versatile donor site of myomucosal flaps. Technical and functional considerations. Head Neck. 2013; 35:109-17. 4. Szeto C, Yoo J, Busato GM, Franklin J, Fung K, Nichols A. The buccinator flap: a review of current clinical applications. Curr Opin Otolaryngol Head Neck
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Surg. 2011; 19:257-62.
5. Zhao Z, Li S, Yan Y, Li Y, Yang M, Mu L, Huang W, Liu Y, Zhai H, Jin J, Ma X. New buccinator myomucosal island flap: anatomic study and clinical
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application. Plast Reconstr Surg. 1999; 104:55-64.
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6. Fang L, Yang M, Wang C, Ma T, Zhao Z, Yin N, Wei L, Yin J. A clinical study of various buccinator musculomucosal flaps for palatal fistulae closure after cleft palate surgery. J Craniofac Surg. 2014; 25:e197-202.
7. Ayad T, Xie L. Facial artery musculomucosal flap in head and neck reconstruction: A systematic review. Head Neck. 2014 May 3. doi: 10.1002/hed.23734.
ACCEPTED MANUSCRIPT 8. Rahpeyma A, Khajehahmadi S. Buccinator-based myomucosal flaps in intraoral reconstruction: A review and new classification. Natl J Maxillofac Surg. 2013; 4:25-32.
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9. Lahiri A, Richard B. Superiorly based facial artery musculomucosal flap for large anterior palatal fistulae in clefts. Cleft Palate Craniofac J. 2007; 44:523-7.
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10. Ferrari S, Ferri A, Bianchi B, Copelli C, Sesenna E. Reconstructing large palate defects: the double buccinator myomucosal island flap. J Oral
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Maxillofac Surg. 2010; 68:924-6.
11. Ferrari S, Copelli C, Bianchi B, Ferri A, Sesenna E. The Bozola flap in oral cavity reconstruction. Oral Oncol. 2012; 48:379-82.
12. Baj A, Rocchetta D, Beltramini G, Giannì AB. FAMM flap reconstruction of
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the inferior lip vermilion: surgery during early infancy. J Plast Reconstr Aesthet Surg. 2008; 61: 425-427.
13. Heller JB, Gabbay JS, Trussler A, Heller MM, Bradley JP. Repair of large nasal
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septal perforations using facial artery musculomucosal (FAMM) flap. Ann Plast Surg. 2005; 55:456-9.
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14. Coronel-Banda ME, Serra-Mestre JM, Serra-Renom JM, Larrea-Terán WP. Reconstruction of nasal septal perforations in cocaine-addicted patients with facial artery mucosa-based perforator flap. Plast Reconstr Surg. 2014; 133:82e-3e. 15. Xie L, Lavigne F, Rahal A, Moubayed SP, Ayad T. Facial artery musculomucosal flap for reconstruction of skull base defects: a cadaveric study. Laryngoscope. 2013; 123:1854-61.
ACCEPTED MANUSCRIPT 16. Patel MR, Taylor RJ, Hackman TG, Germanwala AV, Sasaki-Adams D, Ewend MG, Zanation AM. Beyond the nasoseptal flap: outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction.
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Laryngoscope. 2014; 124:846-52.
ACCEPTED MANUSCRIPT Figure legend. Figure 1. Oro-antral fistula in a 55 year old male patient. Figure 2. Intra-operative picture showing harvesting and rotation of the reverse-FAMM
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flap. Figure 3. Results 13 months after surgery.
Figure 4. Intra-operative picture showing superiorly based FAMM flap for nasal
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septum reconstruction. Figure 5. Flap rotation into the tunnel towards the nose.
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Figure 6. Intra-operative picture showing flap placement inside the nose. Figure 7. An 80 year old male patient affected by a maxillary and orbital basal cell carcinoma extended to the inferior lid.
Figure 8. Intra-operative picture showing extension of the resection: inferior lid and
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skin of the cheek are included.
Figure 9. Intra-operative picture showing the reverse flow FAMM flap used for conjunctiva reconstruction.
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Figure 10. Reconstruction of maxillary defect was achieved with bone grafts and cervico-facial flap. In this picture the pedicle of the reverse flow FAMM flap is also
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shown.
Figure 11. Results of reconstruction 48 months after surgery.
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Sex and age
Diagnosis
Pedicle section
M
Cleft Palate
Anterior hard palate
No
Partial necrosis
Oro-antral fistula
Superior alveolar crest and hard palate
Yes
Palatal wound dehiscence
Normal
Nasal septum perforation
Nasal septum
No
No
Maxillary SCC
Secondary upper lip and commissure reconstruction
No
Dehiscence of donor site suture
Orbital and cheek basalioma
Conjunctiva
Maxillary rhabdomyosarcoma
Secondary upper lip reconstruction
Complications
Mouth opening
Facial nerve damages
Speech
No
Normal
Excellent
Complete
24
No
Normal
Excellent
Complete
13
Normal
No
Normal
Excellent
Complete perforation closure, mild nasal obstruction
11
Partially limited
No
Partially intelligible
Acceptable
Good oral competence
38
Normal
F
64
M 80
F
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F
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61
M
Cosmesis
Reconstruction effectiveness
F-UP (Months)
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Reconstructed site
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Table 1. Patients and Results. (M:Male; F: Female; SCC: squamous cell carcinoma)
No
Venous congestion
Normal
No
Normal
Acceptable
Mild ocular impairment
48
Yes
No
Partially limited
No
Normal
Good
Acceptable oral competence
23
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39
Hard palate SCC
Anterior hard palate
No
No
Normal
No
Maxillary SCC
Palate
Yes
Venous congestion
Normal
No
Nasal SCC
Nasal lateral wall
No
No
Nasal septum perforation
Nasal septum
No
No
Cleft palate
Anterior hard palate
Yes
No
Oronasal fistula
Anterior hard palate
F
M
F
55
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38
M
Complete
70
Normal
Excellent
Complete
51
Normal
No
Normal
Excellent
Complete defect closure, severe nasal obstruction
11
Normal
No
Normal
Excellent
Complete perforation closure, mild nasal obstruction
25
Normal
No
Normal
Excellent
Complete
28
Normal
No
Normal
Excellent
Complete
35
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79
M
Excellent
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70
Normal
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M
Yes
Palatal wound dehiscence
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S0278-2391(14)01792-3
DOI:
10.1016/j.joms.2014.11.017
Reference:
YJOMS 56575
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 2 October 2014 Revised Date:
15 November 2014
Accepted Date: 17 November 2014
Please cite this article as: Ferrari S, Ferri A, Bianchi B, Contadini E, Leporati M, Sesenna E, Head and Neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2014.11.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Head and Neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap.
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Ferrari S, Ferri A, Bianchi B, Contadini E, Leporati M, Sesenna E
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Silvano FERRARI, MD, Associate Professor; Andrea FERRI, MD; Bernardo BIANCHI, MD; Enrico CONTADINI, MD, resident; Massimiliano LEPORATI, MD; Enrico
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SESENNA, MD, full professor, chief.
Maxillo-Facial Surgery Division (Head: Professor Enrico Sesenna); Head and Neck
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Department; University Hospital of Parma.
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Corresponding author: Andrea Ferri. Address: via Gramsci 14; 43100 Parma; Italia. Telphone: +390521703107; +390521703109. Fax: +390521703761.
e-mail: [email protected]
ACCEPTED MANUSCRIPT Head and Neck reconstruction using the superiorly based reversed-flow facial artery myomucosal flap.
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Abstract
Purpose. Myomucosal buccinator flaps use in the reconstruction of oral cavity defects is well established in the international literature, however their use for the
SC
reconstruction of defects not located in the oral cavity has been largely underestimated. Purpose of the study is to describe and review the applications of
M AN U
superiorly based facial artery myomucosal flap in the head and neck reconstruction.
Methods. Retrospective evaluation of twelve patients underwent reconstruction of palate, lip, nasal septum and conjunctiva with reverse-flow FAMM flap Mouth
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opening, speech, reconstruction effectiveness and esthetic outcomes were analyzed.
Results. The patient cohort consisted of 7 males and 5 females, aged between 33
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and 80 years (mean 56.2). No major complication occurred. Cosmetic results were excellent in the largest part of the patient. Functionally, the best results were
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obtained in palate, lip and conjunctiva reconstruction. Nasal reconstruction led to mild air-way obstruction in 2 cases and severe obstruction in the other one. Conclusion. The superiorly based FAMM flap plays an important role in the reconstruction of particular defects involving the oral cavity and other distant sites of the head-and-neck area. Its reliability, low morbidity and the optimal results that can be achieved using this technique make this flap a good option for such reconstructions.
ACCEPTED MANUSCRIPT
Each author disclose any commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in any
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M AN U
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submitted manuscript.
ACCEPTED MANUSCRIPT Introduction Buccinator myomucosal flaps are well described in the international literature1. Owing to the very low morbidity related to their harvesting2, the possibility of
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reconstructing mucosal defects with tissue having the same features as the resected tissue, and to their reliability, these flaps are presently widely used worldwide3. Some recent reviews have indicated that the main indication of these
SC
flaps is reconstruction of oral cavity defects, including defects of the floor of the mouth, tongue, soft and hard palate, and oropharynx4. Conversely, the use of
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buccinators flaps, particularly facial artery myomucosal flaps (FAMM flaps), for the reconstruction of defects not located in the oral cavity has been largely underestimated in international publications. The superiorly based facial artery myomucosal flap is a variation of the FAMM flap first described by Zhao et al. in
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19995. This flap is based on the retrograde flow provided by the facial artery; the pivot point is located in the upper vestibula, ensuring a wide arch of rotation that allows reconstruction of “upper-located” defects, including the anterior portion of
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the hard palate, nasal septum, skull base, and conjunctiva. Few papers focusing on this flap have been published, each of which has emphasized reconstruction of a
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specific site. However, a comprehensive review of the clinical application of this flap is lacking in the English-language literature. The purpose of this paper was to analyze the authors’ experience with the superiorly based FAMM flap, focusing on its indications, advantages, and limits, in head-and-neck reconstruction.
Surgical technique
ACCEPTED MANUSCRIPT Harvesting of the flap starts with forced mouth opening and identification of the facial artery pattern using a portable Doppler probe. Once the facial artery has been identified, the flap is designed including the artery, taking care to preserve
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Stensen’s duct: the flap is usually a fusiform or “shuttle” shape. The first incision is carried out in the anterior and inferior aspects of the flap: the buccinator muscle is identified, and dissection proceeds in a blunt fashion through the fat tissue
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underlining the buccinator, where the facial artery arising from the mandibular area is identified, ligated, and cut. The medial and lateral margins of the flap are
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incised, and the flap is elevated, including the facial artery, which can be followed up to the superior buccal sulcus where the flap is based. Depending on the need for reconstruction, the superior incision can be extended up to the canine, if the nasal cavity needs to be reached; if the conjunctiva has to be reconstructed, dissection of
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the flap’s pedicle proceeds up the nasal base to increase its arch of rotation. Once the flap has reached its recipient site, reconstruction is completed, and the donor site is closed primarily; otherwise, in the case of large flap harvesting, the buccal
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fat pad is advanced.
Patients
To address the research purpose a retrospective evaluation of patients underwent reconstruction using a superiorly based FAMM flap between January 1, 2000 to December 31, 2013 was conducted. Owing to the retrospective nature of the study, exemption from institutional review board approval was granted by our institution. The manuscript was written in compliance with the Declaration of
ACCEPTED MANUSCRIPT Helsinki. Patients were evaluated concerning complications, donor site morbidity, cosmesis and functional outcome related to the reconstructed site. Donor site morbidity was evaluated to assess the mouth opening (limited, partially
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limited or normal), damage to the facial nerve branches (permanent palsy, temporary palsy or none) and speech (unintelligible, partially intelligible or normal). Cosmesis was assessed by the patient as poor, acceptable, good or
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excellent. Functional evaluation differed from site to site: palatal fistula resolution of oro-nasal communication was assessed as absent (same condition before
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surgery), incomplete (partial resolution of symptoms with liquid reflux and air communication), or complete (return to normal condition). Upper lip reconstruction was functionally evaluated concerning oral competence (poor, acceptable, or normal). Functional evaluation of nasal reconstruction concerned
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closure of perforation or defect (incomplete or complete) and nasal obstruction (severe, partial, or none). Finally, the patient who underwent reconstruction of the conjunctiva was evaluated for ocular impairments that were assessed as severe
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(pain, visual deficits, severe keratitis, or corneal ulceration), mild (lagophthalmos,
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mild keratitis, or mild pain), absent (restoration of normal ocular function).
Results
The patient sample consisted of 12 patients among 85 undergoing reconstruction of head-and-neck defects using buccinator myomucosal flaps. The patient cohort consisted of 7 males and 5 females, aged between 33 and 80 years (mean 56.2). Data are summarized in Table 1. The defect site included the anterior hard palate in 6 patients affected by palate fistula, upper lip in 2 patients
ACCEPTED MANUSCRIPT with previously treated squamous cell carcinoma or rhabdomyosarcoma of the vermillion, nasal septum in 2 patients with septum perforation, lateral nasal wall in 1 patient with nasal mucosa carcinoma, and inferior conjunctiva in one patient
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treated for an infra-orbital cutaneous basal cell carcinoma. Forced mouth opening was applied during the first post-operative week in 5 patients underwent anterior palate reconstruction. Resection of the vascular
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pedicle was required in 5 patients and was performed under local anesthesia between 20 and 45 days after the first surgery. In 2 patients treated for nasal
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septum reconstruction, a secondary revision surgery was required to reduce the bulk of the flap that caused nasal obstruction.
All of the flaps were harvested and transposed successfully. No major complication occurred. Minor complications included dehiscence of the palatal wound in 2
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patients, dehiscence of the donor site suture in 1 case, venous congestion in 2 cases that underwent spontaneous resolution after 4–6 days, partial necrosis of 1 flap used for palatal fistula closure that was treated with debridement and suture
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replacement without interference with patient outcome. Donor site morbidity evaluation revealed, as expected, optimal outcomes with no
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cases of mouth opening severe limitation or permanent facial nerve damage, and normal speech and diet in most patients. The largest majority of subjects showed excellent cosmetic results. Functionally, the superiorly based FAMM flap was very effective for oro-nasal fistula treatment, with complete resolution in all patients. Additionally, the analysis of the upper lip reconstruction revealed good results, especially considering that both these patients were previously treated with surgery and radiation therapy for their malignancies. Reconstruction of the nasal
ACCEPTED MANUSCRIPT mucosa led to optimal results when closure of the defect was considered, while nasal function evaluation revealed partial obstruction in most patients and severe obstruction in one. Finally, the patient who underwent conjunctiva reconstruction
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showed an acceptable outcome with lagophthalmos and the requirement for ocular ointment; however, scarring on the periocular complex related to major surgery strongly biased this evaluation and caused difficulty regarding
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understanding the outcome related to conjunctiva reconstruction alone.
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Discussion
At present, the major role played by myomucosal buccinator flaps in the reconstruction of oral cavity defects is well established in the international literature6. The use of these flaps has reduced the indication for free flap
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reconstruction, thus improving functional and esthetic results and simultaneously tremendously reducing morbidity for the patient7. The selection of the buccinator flap to use, based on the defect site, neck treatment, dentition and facial vessel
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availability represents one of the key points in such reconstructions. The purpose of the paper is to review the indications for the use of the reverse flow FAMM flap.
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The superiorly based/reversed-flow FAMM flap differs from other buccinator flaps not only regarding the pivot of the pedicle, but also because of its particular perfusion pattern. Arterial vascularization is provided by a retrograde flow that arises from the angular branch of the facial artery and that receives some adjunctive flow from the infra-orbitary and skull base branches. Despite this retrograde flow, several authors have confirmed its reliability, even if venous drainage is provided only by the submucosal plexus and not by preservation of the
ACCEPTED MANUSCRIPT facial vein8. Some others advocate for caution when performing reverse-flow FAMM flap because of possible vascular anomalies and a steep learning curve; however, in our series no difficulties were encountered.
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The peculiar position of the pedicle’s pivot allows a unique arch of rotation that is extremely useful when the upper and distant sites, such as the anterior hard palate, upper lip, nose, skull base and conjunctiva, need to be reached. At each of these
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sites, this flap provides peculiar advantages that enable its use as a first-line treatment in the reconstruction of defects involving these areas.
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When defects of the anterior hard palate are approached, the use of reverse FAMM flaps offers several advantages. The superior position of the pedicle pivot ensures the possibility to also reach the most anterior palatal area without interference with the patient’s dentition; therefore, teeth removal is required very rarely9.
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However, we usually prefer a forced mouth opening during the first week after surgery to avoid accidental flap damage during biting, rather than to prevent trismus, as we did in 5 patients of the series here reported. The pedicle section is
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not always required; however, we found that patient who underwent this procedure benefited in terms of mouth opening and oral comfort. Compared with
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other buccinator flaps10, 11, the superiorly based is the only one that can easily reach the most anterior part of the hard palate, particularly in dentate patients: an inferiorly based flap’s pedicle is too far from the recipient site, with a high risk of flap damage or detachment; a posteriorly based flap cannot reach the anterior hard palate; and island flaps require a more complex technique without a great increase in the flap’s arch of rotation. Our results confirm the reliability of
ACCEPTED MANUSCRIPT myomucosal buccinator flaps when anterior palatal fistulas or clefts are approached using this technique. (Figures 1, 2, 3). Upper lip reconstruction represents a real challenge in many patients who
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undergo lip resections or are affected by lip defects after traumas: for defects involving less than one-third of the lip, the use of the inferior one as a donor site likely ensures the most reliable and cosmetic results. However, when total or
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subtotal upper lip defects are approached, the superiorly based FAMM ensures a large amount of mucosa availability, thus allowing safe and precise reconstruction
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of the lip12. The morbidity is very low, post-operative forced mouth opening is often unnecessary in these patients and required only when there is risk for pedicle biting. We usually perform pedicle resection after 3 weeks to optimize the oral vestibular shape and release the lip, thus improving mouth opening. As in the
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patient presented here, the mucosa of the flap usually undergoes spontaneous reepithelialization, which ensures optimal results in terms of cosmesis. The possibility of the reconstruction of sites far from the oral cavity represents the
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most critical feature of the reversed-flow FAMM flap. If vestibular dissection proceeds up to the canine, it is easy to rotate the flap into the nasal cavity, thus
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facilitating the reconstruction of several defects. Nasal septum perforation, independently from its origin, represents one of these defects13. When other nasal flaps are not available, or the perforation is too extensive for intra-nasal local flap reconstruction, the large amount of healthy mucosa provided by the superiorly based FAMM flap represents an ideal solution14. In these cases, the most critical point is the insetting of the flap: in our experience, a closed or endoscopic approach was fairly utopian, and “open rhinoplasty” access was preferable. Thus,
ACCEPTED MANUSCRIPT we could control the flap insetting and perform sutures that represented probably the most difficult part of the procedure, particularly in the posterior area of the septum. We avoided lateral rhinotomy access for septum defects to avoid scars and
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retraction, thus ensuring optimal cosmesis; however, this certainly represents an option, as advocated by other authors. During flap transposition, the anterior nasal spine is usually exposed to an increased space for flap transfer; however, widening
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by drilling is usually unnecessary. To maximize the arch of rotation, dissection of the oral vestibulum up to the canine area is mandatory and ensures safe and easy
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rotation into the oral cavity and the possibility to orientate the flap with the mucosal aspect in the correct position for lining reconstruction. (Figures 4, 5, 6). Excessive bulk, particularly in males, in whom the buccinator muscle is more represented, is the most critical issue. We needed to revise 1 flap with submucosal
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debridement to improve air flow: the procedure was straightforward and yielded satisfactory results; however, real improvements were usually observed only after 6–12 months, likely because of atrophy of the buccinator muscular component of
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the flap.
The same principles of nasal septum reconstruction were employed for lateral
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nasal wall reconstruction for malignancies. In those cases, lateral rhinotomy represents the ideal approach to achieving adequate field exposure for safe control of malignant tumor margins. Once in the nose, the path to the skull base is short: we did not use the superiorly based/reversed-flow FAMM flap for skull base reconstruction; however, some authors have described its harvesting and transposition in specimens15, while others have confirmed the possibility of its application in anterior fossa base
ACCEPTED MANUSCRIPT reconstruction16. Indeed, the pedicle length allows the skull base to be reached, and the flap has adequate bulk and mucosa for skull base reconstruction. However, using an endoscopic approach, the achievement of a safe suture and suspension
application of the reversed-flow FAMM flap.
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seems quite difficult, and further studies are needed to confirm this particular
The final, and probably the most fascinating, application of this flap is the
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reconstruction of conjunctiva5. This area represents a major challenge for the reconstructive surgeon, particularly because more extensive resections are often
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required simultaneously. The importance of conjunctiva reconstruction when the inferior lid is resected and the eye is spared is obvious. The mucosa provided by the reversed-flow FAMM flap ensures eye protection and avoids scar retraction with corneal exposure. Furthermore, it allows eye moisture preservation, thus
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increasing the patient’s comfort and eye protection. For conjunctiva reconstruction, accurate pedicle dissection is mandatory to achieve an adequate length to reach the eye; however, simultaneous resection of cheek soft tissues that is usually
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performed for such types of malignancies (as in the patient here presented), makes the dissection and flap transposition more confortable for the surgeon (Figures 7-
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11). Additionally, in these cases, the “time factor” plays a mayor role: debridement of excessive bulk is difficult, and we noticed in our case that, although initially evident, the excess bulk underwent spontaneous regression within 18 months, allowing for satisfactory results, particularly considering the structures resected with the tumor.
Conclusion.
ACCEPTED MANUSCRIPT Of the buccinator myomucosal flaps, the superiorly based / reverse flow FAMM flap plays an important role in the reconstruction of particular defects involving the oral cavity and other distant sites of the head-and-neck area. It is the only
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buccinator flap that can function also as a “loco-regional” flap when employed in nasal, skull base, and conjunctiva reconstruction. Its reliability, low morbidity and the optimal results that can be achieved using this technique make this flap a good
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solution for such reconstructions.
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Conflict of interest: none.
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Funding to disclose: none.
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The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see:
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http://www.textcheck.com/certificate/6awpPe
ACCEPTED MANUSCRIPT References. 1. Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Myomucosal cheek flaps: applications in intraoral reconstruction using three different techniques.
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Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 108:353-9. 2. Ferrari S, Ferri A, Bianchi B, Copelli C, Boni P, Sesenna E. Donor site
morbidity using the buccinator myomucosal island flap. Oral Surg Oral Med
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Oral Pathol Oral Radiol Endod. 2011; 111:306-11.
3. Massarelli O, Baj A, Gobbi R, Soma D, Marelli S, De Riu G, Tullio A, Giannì AB.
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Cheek mucosa: a versatile donor site of myomucosal flaps. Technical and functional considerations. Head Neck. 2013; 35:109-17. 4. Szeto C, Yoo J, Busato GM, Franklin J, Fung K, Nichols A. The buccinator flap: a review of current clinical applications. Curr Opin Otolaryngol Head Neck
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Surg. 2011; 19:257-62.
5. Zhao Z, Li S, Yan Y, Li Y, Yang M, Mu L, Huang W, Liu Y, Zhai H, Jin J, Ma X. New buccinator myomucosal island flap: anatomic study and clinical
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application. Plast Reconstr Surg. 1999; 104:55-64.
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6. Fang L, Yang M, Wang C, Ma T, Zhao Z, Yin N, Wei L, Yin J. A clinical study of various buccinator musculomucosal flaps for palatal fistulae closure after cleft palate surgery. J Craniofac Surg. 2014; 25:e197-202.
7. Ayad T, Xie L. Facial artery musculomucosal flap in head and neck reconstruction: A systematic review. Head Neck. 2014 May 3. doi: 10.1002/hed.23734.
ACCEPTED MANUSCRIPT 8. Rahpeyma A, Khajehahmadi S. Buccinator-based myomucosal flaps in intraoral reconstruction: A review and new classification. Natl J Maxillofac Surg. 2013; 4:25-32.
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9. Lahiri A, Richard B. Superiorly based facial artery musculomucosal flap for large anterior palatal fistulae in clefts. Cleft Palate Craniofac J. 2007; 44:523-7.
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10. Ferrari S, Ferri A, Bianchi B, Copelli C, Sesenna E. Reconstructing large palate defects: the double buccinator myomucosal island flap. J Oral
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Maxillofac Surg. 2010; 68:924-6.
11. Ferrari S, Copelli C, Bianchi B, Ferri A, Sesenna E. The Bozola flap in oral cavity reconstruction. Oral Oncol. 2012; 48:379-82.
12. Baj A, Rocchetta D, Beltramini G, Giannì AB. FAMM flap reconstruction of
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the inferior lip vermilion: surgery during early infancy. J Plast Reconstr Aesthet Surg. 2008; 61: 425-427.
13. Heller JB, Gabbay JS, Trussler A, Heller MM, Bradley JP. Repair of large nasal
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septal perforations using facial artery musculomucosal (FAMM) flap. Ann Plast Surg. 2005; 55:456-9.
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14. Coronel-Banda ME, Serra-Mestre JM, Serra-Renom JM, Larrea-Terán WP. Reconstruction of nasal septal perforations in cocaine-addicted patients with facial artery mucosa-based perforator flap. Plast Reconstr Surg. 2014; 133:82e-3e. 15. Xie L, Lavigne F, Rahal A, Moubayed SP, Ayad T. Facial artery musculomucosal flap for reconstruction of skull base defects: a cadaveric study. Laryngoscope. 2013; 123:1854-61.
ACCEPTED MANUSCRIPT 16. Patel MR, Taylor RJ, Hackman TG, Germanwala AV, Sasaki-Adams D, Ewend MG, Zanation AM. Beyond the nasoseptal flap: outcomes and pearls with secondary flaps in endoscopic endonasal skull base reconstruction.
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Laryngoscope. 2014; 124:846-52.
ACCEPTED MANUSCRIPT Figure legend. Figure 1. Oro-antral fistula in a 55 year old male patient. Figure 2. Intra-operative picture showing harvesting and rotation of the reverse-FAMM
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flap. Figure 3. Results 13 months after surgery.
Figure 4. Intra-operative picture showing superiorly based FAMM flap for nasal
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septum reconstruction. Figure 5. Flap rotation into the tunnel towards the nose.
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Figure 6. Intra-operative picture showing flap placement inside the nose. Figure 7. An 80 year old male patient affected by a maxillary and orbital basal cell carcinoma extended to the inferior lid.
Figure 8. Intra-operative picture showing extension of the resection: inferior lid and
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skin of the cheek are included.
Figure 9. Intra-operative picture showing the reverse flow FAMM flap used for conjunctiva reconstruction.
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Figure 10. Reconstruction of maxillary defect was achieved with bone grafts and cervico-facial flap. In this picture the pedicle of the reverse flow FAMM flap is also
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shown.
Figure 11. Results of reconstruction 48 months after surgery.
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Sex and age
Diagnosis
Pedicle section
M
Cleft Palate
Anterior hard palate
No
Partial necrosis
Oro-antral fistula
Superior alveolar crest and hard palate
Yes
Palatal wound dehiscence
Normal
Nasal septum perforation
Nasal septum
No
No
Maxillary SCC
Secondary upper lip and commissure reconstruction
No
Dehiscence of donor site suture
Orbital and cheek basalioma
Conjunctiva
Maxillary rhabdomyosarcoma
Secondary upper lip reconstruction
Complications
Mouth opening
Facial nerve damages
Speech
No
Normal
Excellent
Complete
24
No
Normal
Excellent
Complete
13
Normal
No
Normal
Excellent
Complete perforation closure, mild nasal obstruction
11
Partially limited
No
Partially intelligible
Acceptable
Good oral competence
38
Normal
F
64
M 80
F
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F
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33
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55
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61
M
Cosmesis
Reconstruction effectiveness
F-UP (Months)
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Reconstructed site
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Table 1. Patients and Results. (M:Male; F: Female; SCC: squamous cell carcinoma)
No
Venous congestion
Normal
No
Normal
Acceptable
Mild ocular impairment
48
Yes
No
Partially limited
No
Normal
Good
Acceptable oral competence
23
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39
Hard palate SCC
Anterior hard palate
No
No
Normal
No
Maxillary SCC
Palate
Yes
Venous congestion
Normal
No
Nasal SCC
Nasal lateral wall
No
No
Nasal septum perforation
Nasal septum
No
No
Cleft palate
Anterior hard palate
Yes
No
Oronasal fistula
Anterior hard palate
F
M
F
55
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38
M
Complete
70
Normal
Excellent
Complete
51
Normal
No
Normal
Excellent
Complete defect closure, severe nasal obstruction
11
Normal
No
Normal
Excellent
Complete perforation closure, mild nasal obstruction
25
Normal
No
Normal
Excellent
Complete
28
Normal
No
Normal
Excellent
Complete
35
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46
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55
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79
M
Excellent
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70
Normal
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M
Yes
Palatal wound dehiscence
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