Oral Oncology 48 (2012) 379382

Contents lists available at SciVerse ScienceDirect

Oral Oncology
journal homepage: www.elsevier.com/locate/oraloncology

The Bozola ap in oral cavity reconstruction

S. Ferrari, C. Copelli , B. Bianchi, A. Ferri, E. Sesenna
Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Via Gramsci 14, Parma (Pr), Italy

a r t i c l e

i n f o

s u m m a r y
The buccinator musculomucosal aps are actually considered the main reconstructive option for smallmoderate defects of the oral mucosa. In this paper we present our experience with the posteriorly based buccinator musculomucosal ap. A retrospective review was performed of all patients who had had a Bozola ap reconstruction at the Operative Unit of Maxillo-Facial Surgery of Parma, Italy, between 2003 and 2010. The Bozola ap was used in 19 patients. In most cases they had defects of the palate (n = 12). All aps were harvested successfully and no major complications occurred. Minor complications were observed in two cases. At the end of the follow up all patients returned to a normal diet without alterations of speech and swallowing. We consider the Bozola ap the rst choice for the reconstruction of defects involving the palate, the cheek and the postero-lateral tongue and oor of the mouth. 2011 Elsevier Ltd. All rights reserved.

Article history: Received 12 March 2011 Accepted 26 October 2011 Available online 6 December 2011 Keywords: Oral cavity defects Mucosal defects Musculomucosal aps Bozola ap Buccal artery and vein

Introduction The resection of tumours of the oral cavity can lead sometimes to small or moderately sized defects involving the mucosa without extension to the adjacent tissues such as bone or skin. Despite of the description and use of different reconstructive techniques during years (healing by secondary intention, sking grafts, local, locoregional or free aps) actually, in order to optimize the functional and aesthetical results, the rst choice is considered to be use of aps with tissue characteristics similar to those of the lost tissues. The cheek mucosa is an ideal donor site thanks to the low morbidity, the rich vascularisation and its reliability. Different techniques were described based on the use of the buccinator musculomucosal ap, an axial pattern ap which can be based either on the buccal or facial arteries (Bozola, FAMM and Zhao aps).17 Whereas the use of the FAMM2 and Zhao3 aps is widely described in literature, less reported are the applications of the musculomucosal ap based posteriorly on the buccal artery, described rstly by Bozola in 1988.1 In this paper we present our experience with this ap, analyzing its anatomy, the surgical technique, the clinical indications and the results obtained. Anatomy The buccinator muscle with the superior constrictor of the pharynx and the orbicularis oris is part of the pharyngeal-buccal Corresponding author. Address: Operative Unit of Maxillo-Facial Surgery, Head and Neck Department, University Hospital of Parma, Via Gramsci 14, 43100 Parma (Pr), Italy. Tel.: +39 0521 703107. E-mail addresses: chiaracopelli@hotmail.it, copkids@tin.it (C. Copelli).
1368-8375/$ - see front matter 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2011.10.016

orbicularis sphincter with the function of sucking, whistling, propelling food during mastication and voiding the buccal cavity. It is deeply situated in the cheek, with its inner surface covered by the mucosa. The outer surface is covered by the ramus of the mandible, the masseter and medial pterygoid muscles, the buccal fat pad and the buccopharyngeal fascia. It is entwined anteriorly with the orbicularis oris muscle, and posteriorly, it inserts in the pterygomandibular raphe. Superiorly, its limit is at the level of the maxilla, and inferiorly, it is in the mandible. The parotid duct pierces the buccinator just opposite to the second upper molar, slightly above the center of the muscle.1,8 The arterial irrigation of the buccinator derives from three main origins. The buccal artery reaches the posterior half of the muscle, it is a branch of the internal maxillary artery under the pterygoideus muscle and runs forward and down ward to the buccinator muscle, very close to the buccal nerve. The anterior part of the buccinators receives branches from the facial artery. This vessel, after skirting the mandible, approaches the buccal commissure following a deep, almost horizontal course. One centimetre from the angle of the mouth it gives off a few branches to this muscle.1,811 The posterosuperior alveolar artery, a branch from the internal maxillary, gives off a small branch to the buccinator. Anastomoses between all these arteries are multiple and consistent. The venous drenage is based on several veins originating from the lateral aspect of the muscle, some are comitantes to arteries, others unrelated to the latter. All these veins are tributaries to either a posterior main collector (the pterygoid plexus and the internal maxillary vein) or an anterior collector (the facial vein).1,811 The motor innervation of the buccinator muscle comes from the temporal and cervical divisions of the facial nerve, which converge near the buccal fat pad to form a dense network (buccal

380

S. Ferrari et al. / Oral Oncology 48 (2012) 379382

branches). Several efferent branches reach the deep aspect of the buccal fat pad to distribute into the buccinator. This multiple arrangement allows surgeons to elevate part of the muscle without denervating the remaining portion. The buccal sensitive branch of the inferior maxillary nerve pierces the posterior half of the buccinators. This nerve arborizes extensively on the buccal mucosa.1,8

Materials and methods A retrospective review was performed of all patients who had had a posteriorly based buccinator musculomucosal ap reconstruction at the Operative Unit of Maxillo-Facial Surgery of the University Hospital of Parma, Italy, between 2003 and 2010. Flap harvesting The ap is elevated from the omolateral side of the defect. Two to three peri-labial traction stitches are positioned to expose and to stretch out the cheek mucosa. Once the buccal artery is localized by Doppler ultrasound the ap is outlined keeping the following limits: The superior margin is at least 0.5 cm below the duct papilla. To preserve the parotid duct, which pierces the buccinator just opposite the second superior molar, is very important to avoid the risk of an obstructive sialoadenitis: Anteriorly the ap can end no further than 1 cm behind the oral commissure. The overcoming of this limit determines an anaesthetical cicatricial retraction of the oral commissure. The inferior margin depends from the dimensions of the defect. The maximal ap size possible is 45 cm in a superiorinferior direction and 7 cm in an anteroposterior direction. The posterior limit is constituted by the pteryrigomandibular raphe where the vascular pedicle enters the ap. After inltrating the ap margins with a solution of local anaesthetic and adrenalin 1%, the buccal mucosa and the buccinator muscle are incised and elevated medially from the buccopharyngeal fascia in an anterior to posterior direction. The labial artery, several small branches from the facial artery and anterior venous tributaries from the pterygoid plexus are ligated. The buccopharyngeal fascia should be preserved in order to prevent herniation of the buccal fat pad and to avoid injury to branches of the facial nerve. The dissection proceeds posteriorly until to the pterigomandibular raphe. The arc of rotation of the ap has its pivot point posterior to the tuberosity of the maxilla, at the base of the vascular pedicle. During the rotation and transfer to the defect, great attention must be taken to avoid forming excessive kinks and twists in the pedicle. For the reconstruction of palatal defects the incision can be extended postero-inferiorly over the pterigomandibular raphe, in order to increase the pedicle arch of rotation. When the patient is dentate, care is taken that the pedicle does not interpose between the molar teeth, as this may interfere with mastication and create damage to the pedicle. When not involved in the resection, sometimes can be necessary the extraction of the third molar to facilitate the passage of the ap pedicle in the retromolar area. Closure of the donor site The donor area can be closed by direct suture of the muscular and mucosal planes. After the harvesting of aps larger than 3 cm, in order to avoid tension and secondary trisma, the buccal

Figure 1 Donor site closure with buccal fat pad transposition.

fat pad can be exposed and used to close part of the donor site defect (Fig. 1). Results Between 2003 and 2010 the reconstruction of an oral cavity defect with a posteriorly based musculomucosal ap was performed in 19 patients. They were 8 male and 11 female with a mean age of 58.8 years (range: 3275 years). The patients characteristics and the indications for surgery are summarized in Table 1. Thirteen aps were used to close defects following excision of oral cavity malignancies, two were performed after the resection of benign tumours of the palate and the remaining two to close oro-antral stulas. In most cases the ap was used to close defects of the palate (n = 12) (Figs. 2 and 3), less frequently the defects involved the cheek, the oor of the mouth and the tongue. Six patients underwent a neck dissection, they had a squamous cell cancer of the tongue (n = 4), of the oor of the mouth (n = 1) and of the cheek (n = 1). In one case two Bozola aps were harvested bilaterally to cover a larger defect involving the palate. Thirteen patients were dentate and the extraction of one or more molars during the resection or the reconstruction was performed in ve cases. The mean total surgical time was 2.1 h (range: 13 h). The ap harvesting time ranged from 20 to 40 min. The donor site was closed directly in 9 cases and with the buccal fat pad in the remaining 10 cases. All aps were harvested successfully. No major complications occurred. In one case we observed a partial marginal necrosis of the ap and in one patient a partial dehiscence of the suture. In both cases the wound had healed by secondary intention with good functional outcome and no further interventions. A second surgical procedure was performed from 3 weeks to 3 months after the rst intervention to debulk and to section the pedicle of the ap. In two cases it was performed under general anaesthesia because of the serious limitation of the mouth opening and the low compliance of the patient. In the remaining cases it was performed with local anaesthesia without hospitalization. At the end of the follow up all patients returned to a normal diet without alterations of speech and swallowing. Evaluating the mouth opening we observed no limitations in the majority of patients (n = 16) and a minimal limitation in the remaining 3 cases. In all patients we had a complete preservation of the oral

S. Ferrari et al. / Oral Oncology 48 (2012) 379382 Table 1 Patients characteristics. No. Age <40 4060 >60 Sex Male Female Pathology Squamous cell ca. Muco-epidermoid ca. Adenocarcinoma Pleomorphus adenoma Oro-antral stula Site Posterior palate Median palate Bilateral palate Cheek Floor of the mouth Tongue 1 12 6 8 11 7 6 2 2 2 6 5 1 2 1 4

381

buccinator ap based on the buccal artery and the FAMM and the Zhao aps based on the facial artery.16 The anatomical and technical basis for the rst of these ap were illustrated in 1988 by Bozola1 who used it for palatal clefts and for 1 case of palatal carcinoma. Actually the main application of this ap is the reconstruction oral cavity defects following oncological resections. The sites that can be reconstructed are:5,1215 Hard and soft palate, even if the defect crosses the midline. Maxillary tuberosity and alveolar crest. Cheek. Retromolar area. Tonsillar area. Posterior oor of the mouth. Postero-lateral defects of the tongue.

Figure 2 Fifty-eight years old patient with a palate adenocarcinoma (a). Postoperative appearance 8 months after the tumour resection and the primary reconstruction with a Bozola ap (b).

commissure symmetry without aesthetical alterations. Six patients complained about a mild scarring alteration of the cheek with palpable brosis that didnt interfere with oral function. Discussion The musculomucosal buccinator aps are actually considered the rst choice for the reconstruction of small or moderate oral cavity defects. They in fact provide similarly tissue with characteristics similar to those of the lost ones, they are remarkably elastic and malleable, and can be harvested quickly without morbidity to the donor site. Different techniques were described basing mainly on the anatomy of the vascular pedicle: the posteriorly based

The possibility to reconstruct mucosal defects with mucosa allows to obtain optimal results both in term of function, acceptance and comfort for the patient. The sizes of the defects that can be reconstructed with this techniques varies from less than one centimetre to 56 centimetres extending its use from T1 to T3 tumour resections. The simultaneous use of the cheeks of both sides with the harvesting of a double buccinator ap allows the reconstruction of larger bilateral palatal defects. The ap pedicle passes in the retromolar area making the ap positioning independent from the dentature status of the patient. The third molar when present can be removed to avoid the accidental mastication of the pedicle, a wedge could be positioned alternatively for the rst post-operative days (Fig. 4). The low operative time and the low morbidity lead to shorter hospitalization times and allows its use also in older patients and in patients with comorbidities. In our experience, as previously reported, we didnt observed any major complication and we had minor complications in a small number of patients (n = 2), with a partial necrosis of the ap and a dehiscence that healed by secondary intention with good functional outcome and no further interventions. The main complication described is the appearance of trismus during the healing of the donor site. The defect of the cheek can in fact results in muscular and mucosal brosis with subsequent retraction and limitation of mouth opening. This can lead to an important impairment of mastication and speech, with a decrease of the quality of life. This complication can be avoided with some special cares during the surgical procedure and the post-operative period. A particular attention have to be paid during the closure of the donor site. A direct multiple plain suture should be performed only for smaller, favourably shaped (fusiform) aps. If larger aps are used the transposition of the buccal fat pad is mandatory for the closure to avoid retraction and brosis.16 It usually undergoes reepithelialization within 34 weeks allowing an optimal lining reconstruction. Moreover, during the rst months (12) after

Figure 3 Sixty-two years old patient with a low grade muco-epidermoid carcinoma of the palate (a). The tumour was resected and the defect was reconstructed with a Bozola ap. Intraoperative view of the defect and of the ap (b). The donor site was closed with the buccal fat pad transposition (c).

382

S. Ferrari et al. / Oral Oncology 48 (2012) 379382

Conclusions We consider the Bozola ap the rst choice for the reconstruction of defects involving the palate, the cheek and the postero-lateral tongue and oor of the mouth. The reliability, the easy and quick harvesting and the low morbidity make the posteriorly based buccinator musculomucosal ap to prefer to other local or loco-regional aps. In our opinion moreover, for the defects previously indicated, this ap should be preferred to the facial artery based aps. Being based on the buccal artery, in fact, this can be harvested without the necessity to isolate and preserve the facial artery during neck dissections and also in patients with level I nodes metastases. Furthermore, the pedicle rotation and positioning are not inuenced strictly by the denature status of the patient.

Figure 4 Endo-oral post-operative views of the patient 9 months after surgery showing the palatal reconstruction (a) and the perfect healing of the donor site (b).

surgery cheek massages are indicated to minimize the brosis process and improve the tissue stretching.16 When the tongue is reconstructed or for particular prosthetic necessities, at about three weeks after the rst operation it is possible to section pedicle and reduce the bulking of the ap. This procedures allow to improve the tongue motility and to obtain an adequate prosthetic positioning. This second surgical procedure generally can be performed with local anaesthesia without hospitalization. General anaesthesia is reserved to patients with a serious limitation of the mouth opening and a low compliance. The main advantages of the Bozola ap are: The possibility to reconstruct the oral cavity mucosa with a similar tissue. The proximity to the recipient site. The endo-oral harvesting avoiding external deformities and scars. Low operative times: in our experience, similarly to others authors, the harvesting time of the ap ranged between 20 and 40 min. The possibility to reach almost all the oral cavity sites, even if crossing the midline, thanks to its arc of rotation and the good amount of tissue available. The low morbidity on the donor site: it can be closed directly or with adjacent tissues (buccal fat pad). The good vascularization of the tissue that avoid retraction even if after radiotherapy. Unlike the facial artery based aps, it can be harvested independently from the necessity to perform a neck dissection and it can be harvested also in patients with level I nodes metastases. Shorter hospitalization times. Technical simplicity not needing microsurgical experience. Versatility and reliability. Unlike the facial artery based aps, the pedicle rotation and positioning are not inuenced strictly by the denature status of the patient. Evaluating the disadvantages of this ap, they are mainly related to: The limited amount of tissue available, not suitable for large complex defects. The not reacheability of the anteriorer sites of the oral cavity such as the anterior tongue or the anterior oor of the mouth. The necessity sometimes to perform a second surgical procedure to section the pedicle and to reduce the bulk of the ap.

Conict of interest statement All authors disclose any nancial and personal relationships with other people or organisations that could inappropriately inuence (bias) their work. References
1. Bozola AR, Gasques JAL, Carriquiry CE, Cardoso de Oliveira M. The buccinator musculomucosal ap: anatomic study and clinical application. Plast Reconstr Surg 1989;84:2507. 2. Pribaz JJ, Stephens W, Crespo L, Gifford G. A new buccinators myomucosal island pedicle ap: anatomic study and case report. Plast Reconstr Surg 1991;88:3945. 3. Zhao Z, Li S, Yan Y, Li Y, Yang M, Mu L, et al. New buccinators myomucosal island ap: anatomic study and clinical application. Plast Reconstr Surg 1999;104:5564. 4. Tezel E. Buccal mucosal aps: a review. Plast Reconstr Surg 2002;109:73541. 5. Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E. Myomucosal cheek aps: applications in intraoral reconstruction using three different techniques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:3539. 6. Ferrari S, Caradonna L, Bianchi B, Balestrieri A, Sesenna E. Facial artery muscolomucosal ap in reconstruction of the oral cavity. Riv Ital Chir Max-Fac 2004;15:1823. 7. Ferrari S, Balestreri A, Bianchi B, Multinu A, Ferri A, Sesenna E. Buccinator myomucosal Island ap for reconstruction of the oor of the mouth. J Oral Maxillofac Surg 2008;66:394400. 8. Carstens MH, Stofman GT, Sotereanos GC. The buccinators myomucosal island pedicle ap: anatomic study and case report. Plast Reconstr Surg 1991;88:3945. 9. Soikkonen K, Wolf J, Hietanen J, Mattila K. Three main arteries of the face and their tortuosity. Br J Oral Maxillofac Surg 1991;29:3958. 10. Pinar YA, Bilge O, Govsa F. Anatomic study of the blood supply of perioral region. Clin Anat 2005;18:3309. 11. Van Lierop AC, Fagan JJ. Buccinator myomucosal ap: clinical results and review of anatomy, surgical technique and applications. J Laryngol Otol 2008;122:1817. 12. Licameli GR, Dolan R. Buccinator muscolomucosal ap. Application in intraoral reconstruction. Arch Otolaryngol Head Neck Surg 1998;124:6972. 13. Massarelli O, Gobbi R, Raho MT, Tullio A. Three-dimensional primary reconstruction of anterior mouth oor and ventral tongue using the trilobed buccinator myomucosal island ap. Int J Oral Maxillofac Surg 2008;37:91722. 14. 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. 15. Ferrari S, Ferri A, Bianchi B, Copelli C, Sesenna E. Reconstructing large palate defects: the double buccinator myomucosal island ap. J Oral Maxillofac Surg 2010;68:9246. 16. Ferrari S, Ferri A, Bianchi B, Copelli C, Boni P, Sesenna E. Donor site morbidity using the buccinator myomucosal island ap. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:30611.