|Year : 2014 | Volume
| Issue : 1 | Page : 17-18
Buccinator myomucosal flap in cleft palate repair: Revisited
Department of Plastic, Cosmetic and Reconstructive Surgery, Fortis Hospital, New Delhi, India
|Date of Web Publication||5-Feb-2014|
Department of Plastic, Cosmetic and Reconstructive Surgery, Fortis Hospital, A Block, Shalimar Bagh, New Delhi - 110 088
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gupta R. Buccinator myomucosal flap in cleft palate repair: Revisited. J Cleft Lip Palate Craniofac Anomal 2014;1:17-8
Reconstruction of intra-oral soft-tissue defects due to a variety of conditions such as trauma, congenital defects such as cleft palate and related fistulae and oncologic resections has remained a challenge. Though various reconstructive options such as local tissue, muscle, myocutaneous flaps, fasciocutaneous flaps and free flaps are available, the primary goal in such reconstruction remains, replacement with tissue that is similar anatomically and physiologically to the resected tissue. The tissues that are locally available are: Palatal mucoperiosteal, tongue myomucosal, labial and cheek flaps.
The cheek is dominated by buccinator muscle which originates from pterygomandibular raphe posteriorly and blends with orbicularis oris anteriorly. It has maxillary vestibule as the upper limit and mandibular vestibule as a lower limit. It is pierced by Stenson's duct. The Buccinator muscle and related cheek mucosa is richly supplied by anterior, inferior and posterior buccal branches of the facial artery, posterosuperior alveolar and buccal branches of the maxillary artery and some fine branches from infra-orbital artery.  This area is drained by facial vein and pterygoid venous plexus. The sensory nerve supply is by buccal branch of the mandibular nerve and motor nerve supply by a facial nerve branches. The cheek mucosa also has numerous minor salivary glands. These attributes make the cheek area, an ideal source of flaps for intra-oral reconstructive needs.
As nearly all mucomuscular flaps based in cheek have buccinator muscle as a flap component or pedicle base, carrying the blood supply, the ideal term for these flaps is 'Buccinator Myomucosal Flaps' (BMMF) to differentiate these from other buccal flaps. Bozola et al. in 1989  described posteriorly based BMMF based on buccal artery. Carstens et al. in an article in 1991  described anteriorly based BMMF based on the branches of the facial artery. In research in 1992, Pribaz et al.  described facial artery musculomucosal flap, also based on anterior buccal branches of the facial artery. Zhao et al.  in 1999, after careful cadaveric dissection discovered the contribution of posterior and inferior buccal branches of the facial artery to buccinator area. He also discovered that the soft-tissue around these vascular pedicles can be substantially reduced, thus increasing the arch of rotation, obviating the need of pedicle division and enabling reconstruction either palatal or lingual to alveolar arches. He thus described the superiorly and inferiorly based islanded BMMF. In addition to these axial flaps, BMMF can also be raised as a random pattern flap on a pedicle of buccinator muscle. Most of these flaps can be raised in a 1:5 ratio, thus providing an excellent reach.
Due to above mentioned unique attributes and proximity to location, BMMF have been used in cleft palate repair. These flaps provide an ideal tissue replacement in situations of wide cleft palate for either nasal or oral layer or both. BMMF also provide well-vascularized tissue in situations of short scarred palate. These also help in coverage of fistulae. BMMF have also been electively used for palatal lengthening during primary or secondary palatoplasty. Mukherji,  Kaplan,  Maeda et al.,  Freedlander and Jackson  described the use of BMMF for various indications as an adjunct to Pushback procedure. Mann and Fisher,  Gupta et al.  described extensive use of BMMF for several indications, during the course of and as modifications in Furlow Repair.
Authors in this paper have described several innovative uses of posteriorly based BMMF during the course of palatoplasty, based on their experience in various surgical situations. The flaps were carried out to decrease tension at suture lines, as well as bringing in well-vascularized tissue, into an area of tissue shortage in wide clefts. They also employed BMMF for the purpose of palatal lengthening. During the course of Furlow palatoplasties, three different modifications can be carried out to increase anteroposterior palatal length. These are, firstly the Z-plasty itself, which causes an increase of 1.75 times in the area of Z-plasty. The second modification is, islanding of mucoperiosteal flaps on greater palatine pedicles, which allows further medial and posterior movement of these flaps and as a result, palate itself. The third modification is, use of BMMF in nasal layer, oral layer or both as per the need, which causes a further posterior movement of the reconstructed, overlapped muscle sling.  A palatal repair which leaves a significant velopharyngeal gap as measured post-operatively is likely to result in velopharyngeal incompetence. Hence, the importance of these modifications, which actively lengthen the palate, which thus is more likely to close the velopharyngeal gap during speech. ,,
The authors in this study have also described the use of BMMF for coverage of palatal fistulae and in case of short scarred palate in a secondary situation. They need to strengthen their results by a better speech pathology analysis and nasendoscopy to study the fate of buccal flaps post-operatively as well as, velopharyngeal gap.
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