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Original Article
Buccinator myomucosal flap in cleft palate
repair: Revisited
Bhaumik Bhayani1
ABSTRACT
Objective: To present various ways of transfer
and result of buccinator myomucosal flap (BMMF)
in primary and secondary repair of palatal cleft
and palate fistula. Design: This study has been
designed on the basis of a clinical experience and
literature search. Route of single or two BMMF(s)
transfer was either lateral or posterior to the
greater palatine neurovascular bundle. The flap
has been used to repair defect in nasal layer, oral
layer, or in combined nasal as well as oral layer
of the palate. Materials and Methods: More than
160 palatoplasties have undergone palate repair
with the use of BMMFs between 1999 and 2011.
The analysis includes 98 palate repair. Unilateral
flap was used most commonly in primary repair
of nasal side of wide unilateral cleft palate (CP);
whereas, two flaps were used mostly in primary
repair of wide bilateral CP and in secondary palate
repair for large fistula. Results: The fistula rate;
in primary palatoplasty patients was 4.8% and in
secondary palatoplasty patients, it was 8.3%. Good
speech has been achieved in primary palatoplasty
patients. After secondary palatoplasty also patients
had good speech following therapy. Conclusion:
The presented technique has been effective in
anatomical and functional repair of wide palatal
defects primary as well as secondary. The literature
has been reviewed along with.
Key words: Buccinator myomucosal flap,
buccal flap, cleft palate, large palatal fistula/
defect, palate fistula, Soft palate lengthening,
velopharyngeal incompetence, wide palatal cleft,
wide cleft palate
1
Consultant Plastic Surgeon, Rajkot, Gujarat, India
Address for correspondence:
Dr. Bhaumik Bhayani,
Heal-Well Hospital, Gujarat Housing Board - M/53, Opp. Swaminarayan
Temple, Kalawad Road, Rajkot-360 001, Gujarat, India.
E-mail: drbhayani54@yahoo.in
Journal of Cleft Lip Palate and Craniofacial Anomalies
Access this article online
Website:
www.jclpca.org
DOI:
10.4103/2348-2125.126540
Quick Response Code:
INTRODUCTION
High fistula rate and inferior speech results are common
after primary repair of substantially wide cleft palates
(CPs). In wide CP, the defect created in nasal layer
after ‘back-cut’ to lengthen it, is very large. Without the
addition of additional vascular tissue; the chances of
fistula, dehiscence, scarring, anterior reattachment of
the reconstructed levator muscular sling, and loss of the
lengthening of soft palate are high.[1] Serious scarring in
hard palate, after secondary healing adversely affects
the maxillary growth and dentition. The patients with
wide CP end up as “cleft palate cripple” after two
or three reparative attempts as far as the dentition,
maxillary growth, and speech are concerned.
To cover the defect in nasal layer after the ‘back-cut’; split
thickness skin graft,[2] buccal mucosa graft,[3,4] Z-plasty,[5,6]
nasal mucosal flap,[7,8] midline posterior pharyngeal
wall flap,[9,10] lateral pharyngeal flap,[11] mucoperiosteal
island flap,[12] buccal mucosal,[1,13-17] and vomer flap[18-20]
have been used. But in substantially large defect, with
exception of buccinator myomucosal flap (BMMF),
Z-plasty, vomer flap, nasal mucosal flap are inadequate;
split thickness skin graft, buccal mucosal graft are
unpredictable; and pharyngeal flaps and mucoperiosteal
islanded flap are potentially hazardous. Except BMMF,
and facial artery musculomucosal (FAMM) flap, none
facilitate combined oral and nasal layer repair.
We are using this flap in repair of primary and secondary
palatoplasty for large palatal defect since 1999. A set of
line diagrams and photographs have been presented to
illustrate the flap anatomy, its transfer and variety of
insetting depending upon the defect. Observations made
in 98 palate surgery patients are presented.
MATERIALS AND METHODS
The data of 98 BMMF performed in 50 primary
palatoplasty and 48 secondary palatoplasty were analyzed
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Bhayani: Buccinator myomucosal flap in palatoplasty
retrospectively. Patients’ age, type of cleft, fistula rate,
flap necrosis, and donor site morbidity were recorded.
In all patients the speech evaluation consisting of nasal
emission, hypernasality, hyponasality, and phonation and
articulation was done by a senior speech therapist. The
quality of speech was ranked as normal, mild, moderate,
or severely compromised. The children of less than
3 years of age at surgery were assessed postoperatively at
completion of 3 years or little late. The children of more
than 3 years of age at surgery were assessed for speech at
preoperative and then at 6 months postoperatively, and
finally at the completion of speech therapy.
Surgical anatomy of buccal myomucosal flap
Neurovascular supply
Buccal artery is a branch from second part of internal
maxillary artery, accompanying buccal vein and buccal
nerve a branch of mandibular nerve enter the flap
base from the lateral side at posteroinferior part of
the buccinator muscle at buccal sulcus lateral to the
pterygomandibular rhaphe. The branches of the buccal
artery, vein and the nerve fan out anteriorly from the
narrow base of the flap [Figures 1 and 2]. The buccal
vessels generously supply the buccinator muscle and the
underlying cheek mucosa as well as the mucosa overlying
the superior alveolar ridge and lateral part of soft palate.[17]
The terminal branches of the buccal artery at the anterior
part of the cheek mucosa anastomose with the ramified
branches of the facial artery as it courses upward and
anteriorly towards the nose.[16] The buccal myomucosal
flap has a rich venous drainage system composed of
internal maxillary vein, anteriorly tributaries of facial
vein, and posteriorly pterygoid plexus.[17] Motor supply of
buccinator muscle is through the lower buccal branches
of facial nerve, entering the muscle from the lateral aspect.
Figure 1: Neurovascular supply of buccal myomucosal flap. 1 = Second
part of maxillary artery, 2 = buccal artery, 3 = buccal nerve, 4 = buccinator
muscle, 5 = facial artery
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This vascular supply gives this flap the virtue of an axial
pattern myomucosal flap. As the buccal nerve enters the
cheek mucosa at the base of the flap in proximity of the
buccal artery, this flap naturally becomes a sensate flap.
Flap design
A posteriorly-based pedicle flap is raised from cheek
mucosa. The flap is pear-shaped and narrow at the
base. It broadens anteriorly and tapers at distal end. In
1-1.5-year-old child, the flap size is 1.5-2 cm in width ×
4-5 cm in length. The size is bigger in grown up children
and adults. The maximum size can be 4 cm × 7 cm.
The flap can be islanded to facilitate rotation. Its base
width, a little less than the length of pterygomandibular
raphe, is kept, to avoid flap congestion and ‘tip necrosis’.
It allows easy and safe rotation and turn over. This width
of base does not obstruct molar occlusion and allows
a tension free closure of the donor defect without the
need of undermining.
The upper border of the flap is marked at least 3 mm
below the opening of parotid duct opposite the crown
of the second molar of the maxilla. The distal end of the
flap falls short of oral commissure by 0.5-1.0 cm to avoid
distortion. The flap reaches anteriorly up to the anterior
alveolar ridge; medially across the palate to the opposite
greater palatine neurovascular bundle; posteriorly up
to the base of the uvula [Figure 3]. This flap tolerates
moderate stretching, pressure, and 180 degree rotation
and twisting due to its inherent suppleness and elasticity.
Indication
Primary palate repair
Complete palate repair by Veau-Wardill-Kilner
palatoplasty was carried out. Greater palatine
Figure 2: 1 = Buccinator myomucosal flap (BMMF), 2 = buccal artery, 3 =
facial artery, 4 = parotid duct opening, 5 = greater palatine neurovascular
bundle, 6 = proposed extension of BMMF
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Bhayani: Buccinator myomucosal flap in palatoplasty
neurovascular bundle is freed generously. The
innervation of the palatal muscles are preserved as is
essential for good muscular action postoperatively.[1]
A transverse back-cut is made on each side of nasal
mucosa 0.5 cm behind the edge of hard palate
for the retrodisplacement of the soft palate. The
levator muscular sling is reconstructed in midline
with 4/0 vicryl mattress sutures. The nasal side of
the alveolar and hard palatal cleft is closed using
existing mucoperiosteal flaps from vomer and edges
of the alveolar cleft. Thereafter, BMMF is planned for
remaining defect.
Secondary palate repair
For the fistula in hard palate, the nasal layer closure
is done using hinged flaps from the surrounding
marginal mucoperiosteum. If that is not sufficient,
bilateral BMMF for oral as well as nasal layer closure
is planned. Raising the mucoperiosteal flaps from the
rest of the hard palate and freeing of the greater palatine
neurovascular bundle is carried out. If the soft palate is
short and scarred with velopharyngeal incompetence
(VPI) a ‘back-cut’ is given in the nasal layer to release
the levators and palatopharyngeus from the hard palate
edge and lengthen the soft palate. At this point the
placement of the hard palatal mucoperiosteal flaps with
BMMF and the route of the flap transfer is decided. As
per the need, unilateral or bilateral flaps are harvested.
Flap dissection
After the application of traction sutures at lip margin
and applying moderate counter pressure on cheek from
outside, the flap is marked and incised in composite
thickness comprising of mucosa and buccinator muscle,
sparing the buccopharyngeal fascia. Preservation of
the buccopharyngeal fascia prevents herniation of the
buccal fat pad and inadvertent injury to the branches of
the facial nerve. The flap is elevated from the anterior
end to the base. The dissection of the flap is easy
through a loose areolar plane between the buccinator
muscle and the buccopharyngeal fascia. The flap donor
Figure 3: Dissected BMMF and its reach: BMMF (*) and Lt. sided
mucoperiosteal flap (o)
Journal of Cleft Lip Palate and Craniofacial Anomalies
defect is closed primarily. The parotid duct opening is
carefully preserved.
Flap transfer and inset
The dissected flap is transferred to the palatal defect
either from posterior or from lateral side of the greater
palatine neurovascular bundle. For the nasal layer
defect, the flap is transferred through a tunnel, dissected
out in to the soft palate, posterior to the ‘bundle’.
A generous tunnel is created by blunt dissection
through the lateral releasing incision about 0.5 cm
medial to pterygomandibular raphe. To transfer the
flap from lateral side of the neurovascular bundle,
either mucoperiosteal flap from the hard palatal shelf
is elevated or the mucoperiosteum is dissected away
from alveolar ridge. Thus, the BMMF has been used for
palatal reconstruction either transversely or obliquely
anteriorly. This can be used for reconstruction of nasal
lining [Figures 4 and 5], oral surface defect [Figures 6],
or both surfaces simultaneously [Figures 7 and 8] in
variety of situations in primary and secondary unilateral
and bilateral CP surgeries.
a. Single BMMF has been placed transversely to
resurface the nasal layer defect. It can be used in a
wide unilateral cleft lip and palate (UCLP); for large
palate fistula [Figure 4]. It may have ‘L’ inset in wide
bilateral cleft lip and palate (BCLP) [Figure 5] and
in a wide CP.
b. Double BMMF flap may be used for nasal layer
defect resurfacing with ‘T’-shape inset in UCLP and
BCLP. There may be inset in ‘mirrored L-shape’ in
isolated CP [Figure 5] and BCLP.
c. Resurfacing of oral defect: Single flap can be used to
resurface lateral defect in the hard palate [Figure 6]
a b
c
Figure 4: (a) Central palatal fistula with short and scarred soft palate. (b) Soft
palate lengthened by ‘push back’ cuts. Right cheek BMMF (*) brought into
nasal layer for the lining of the fistula as well as push back cuts defect.
(c) Postop photo; fistula is closed and soft palate lengthened
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Bhayani: Buccinator myomucosal flap in palatoplasty
a b
Figure 5: (a) Wide isolated cleft palate with small vomer. (b) A line diagram
depicting restoration of the nasal layer by left BMMF (*) and right BMMF
(o), arranged in “mirrored L” style
a b
Figure 7: (a) A large oronasal fistula following primary palatal repair. (b) The
nasal layer of the fistula is reconstructed using right BMMF (o), passed
through the ‘tunnel’. The oral layer of the fistula is restored by left BMMF
(*). This flap’s pedicle is passing over the deepithelized track on soft palate
and bilateral BMMF can be used to cover the lateral
defect on both the sides.
d. Use of flaps for oral and nasal defects: Combined
bilateral flaps can be used to cover oral and nasal defects
in BCLP and large palate fistula [Figures 7 and 8].
e. Two flaps have been used to cover a large anterior
palate fistula by transferring them along the lateral
raw area in the hard palate.
f. Two flaps could be transferred through different
routes to close the palate fistula [Figures 8] and
in case of complete dehiscence of palatoplasty in
BCLP.
This flap has been used in 50 primary and 48 secondary
palatoplasty. Amongst primary; 26 (52%) are UCLP, 10
(20%) BCLP and 14 (28%) are isolated CPs. Amongst
secondary palatoplasty; 21 (43.9%) had BCLP and 18
(37.5%) had isolated CP [Table 1].
Single BMMF was used for augmentation of nasal layer
in primary UCLP repair. Double flaps were used in
majority of BCLP and secondary palatoplasty [Table 1].
14 January-June 2014 / Vol 1 / Issue 1
a b
c d
Figure 6: (a) Hard palate palate long fistula. (b) Nasal side of the fistula is
closed using marginal hinge flaps (+). (c) The oral side of the fistula and
the rest of the palate is restored by left BMMF (*), right BMMF (o), and the
mucoperiosteal flap (^). (d) Postop photos (^)
a b
c d
Figure 8: (a) Very large oronasal fistula. Left BMMF (*) is brought into the
nasal side, passing over the deepithelized track on the soft palate. (b) A
mucoperiosteal flap (o) covers the oral surface of posterior part of the hard
palate oral side. (c) Right BMMF (^) covers the anterior part of the palate.
(d) Photograph at the completion of surgery
RESULTS
This is a retrospective analysis of the patients undergoing
palatoplasty, detail documentation was available for
98 patients requiring BMMF. Fifty one percent patients
had primary palate surgery, while 49% had secondary
palate surgery [Table 1]. There was a wide variation in
age; from 1 to 25 years; 59% of primary palatoplasties
were done between 1 and 1.5 years of age, while 9% were
operated at reasonably later age. Only 12.5% of secondary
palatoplasties were done in children of 2-3 years, while
31.3% were operated between 3 and 5 years of age. Fifty
percent were operated later than 10 years of age.
The result of palate repair is gauged by occurrence of
palate fistula. In this series of patients where BMMF
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Bhayani: Buccinator myomucosal flap in palatoplasty
Table 1: Use of BMMF in primary and secondary palatoplasties
Primary palate repair
UCLP BCLP CP
(n = 26) (n = 10) (n = 14)
Single BMMF 23 3 8
Bilateral BMMF 3 7 6 22
BMMF: Buccinator myomucosal flap, UCLP: Unilateral cleft lip and palate, BCLP: Bilateral cleft lip and palate, CP: Cleft palate
has been used the palate fistula after primary palate
repair was two out of 50 patients (4.0%). In both the
cases, small perialveolar fistulae occurred which were
closed with local flap later. The overall occurrence of
fistulae after secondary palate repair was 8.3% (four out
of 48 cases). All fistulae were perialveolar, three cases
of BCLP and one case of UCLP. All the CP cases were
fistula free.
One of the bilateral flaps had significant necrosis. This
was placed on the oral surface. However, the flap on the
nasal surface survived fully. Flap pedicle was divided
in eight (8.2%) required flap division as the pedicle
of the flap was covering the occlusal surface of third
molar. None of the patients had significant donor area
problem. None had any compromise in mouth opening.
Ninety percent of primary palatoplasty patients had
normal speech, without speech therapy. Only five patients
(10%) required postoperative speech therapy. In more
than 3 years age group, speech quality was affected with
increasing age, requiring prolonged speech therapy for the
improvement. 79.2% of secondary palatoplasty patients
had poor speech at preoperative assessment. All of them
required postoperative prolonged speech therapy with
substantial improvement in majority of them [Table 2].
DISCUSSION
In clinically wide CP, a generous back-cut is required in
nasal layer for the retrodisplacement of the soft palate to
achieve adequate length. Additional tissue is required
for primary healing of the palate and permanent
lengthening of the soft palate with good mobility.
Baxter et al., (1949) used split thickness skin graft[2]
and Webster and Spina et al., used buccal mucosa graft
to cover nasal layer defects[3,4] created after ‘back-cut’.
But successful take of the graft without scarring was
doubtful.[21] The Z-plasty of nasal mucosa[5,6] was not
effective, due to the deficiency of nasal mucosa in the
longitudinal as well as transverse axis.[21] For the same
reason the use of the Furlow double opposing Z-plasty[22]
to lengthen the nasal layer in very wide CP may not be
effective. All these techniques, including the sliding of
nasal floor mucoperisteum[6,7] are not effective because
Journal of Cleft Lip Palate and Craniofacial Anomalies
Secondary palate repair Total
Oronasal fistula Scarred soft palate Complete dehiscent palate after (n = 98)
(n = 24) (n = 24) primary repair (n = 2)
2 2 0 38
22 2 60
of anterior readhesion of levator muscular sling and loss
of achieved length of soft palate.
Millard island flap[12] leaves large raw area in the hard
palate, and decreases the mobility of the soft palate. It
has been largely abandoned because of the impairment
of the maxillary growth.[1] Posterior pharyngeal wall flap
and lateral pharyngeal wall flap have potential risk of
air way obstruction, hemorrhage, and disturbance in
pharyngeal anatomy.[13,19] These flaps cannot reach into
anterior palate and combined oral and nasal layer repair
is not possible with them. Tongue flap is potentially
risky as the pharyngeal flaps are. It can be used to cover
the only the oral side of the defect.
The FAMM flap is another good option. Its maximum
width can be 1.5-2.0 cm,[17] however we have raised
much larger BMMFs. Sometime primary donor area
closure is not possible in FAMM flap and may require
split thickness skin graft. Anatomical variations of
facial artery are reported. Postoperatively ‘bite blocks’
are necessary and all flaps require flap pedicle division.
When BMMF is used to cover ‘back-cut defect’, the
length of the soft palate was maintained; the flaps were
appreciably matching with the nasal floor mucosa.[16]
In the present series of palatoplasty with BMMF, overall
fistula rate after primary palatoplasty was 4.0% and in
secondary cases it was 8.3% in perialveolar region. No fistula
was found after wide isolated CP repair. There are many
factors responsible for the occurrence of fistula. Increasing
severity of cleft, possibly have more degree of muscular
hypoplasia, smaller palatal shelves, and smaller vomer
with less satisfactory results.[1] Some time in wide isolated
CP and wide BCLP, vomer is not well-developed and there
is very little tissue to provide a flap for nasal layer repair.[18]
It is possible to completely close even the widest CP
with BMMF without the need for further procedure. It is
safe and easy to perform in primary as well as secondary
palatoplasty.[1] The speech result of palatoplasty using
BMMF has been quite satisfactory in present series
[Table 2]. After the secondary palatoplasty improvement
in speech is likely to be due to the successful closure
of fistula and achievement of adequate lengthening of
soft palate with good mobility.
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Bhayani: Buccinator myomucosal flap in palatoplasty
Table 2: Speech assessment after 6 months follow-up
Speech Primary Secondary
palatoplasty (n = 50) palatoplasty (n = 48)
Normal 36 (72%) 27 (56.25%)
Mild compromise 2 (4%) 5 (10.4%)
Moderate compromise 6 (12%) 5 (10.4%)
Severe compromise 6 (12%) 11 (22.9%)
BMMF is a vascular and dependable flap. Vascular
supply of the flap is consistent and profuse. Flap
congestion is occasional and necrosis is rare. It tolerates
stretching, folding, and twisting.
Flap donor area morbidity is negligible. Primary wound
closure is always possible. The parotid duct opening is
not obstructed. By chance if the opening is injured or
obstructed it is of no consequence.[1] No adverse effect
of harvesting the buccinator muscle, particularly on
mastication, oral continence, and mouth opening has
been observed.
Occasionally the flap pedicle needs to be divided
when it obstructs the third molar occlusion. If it is
necessary, the division of the pedicle is usually a
minor procedure which can be performed at outpatient
under local anesthesia or day care under short general
anesthesia. Folded part of the pedicle does not require
deepithelization, as the opposing epithelized surfaces
fuse well with the passage of time. No epithelial cyst
formation is encountered in the infolded flap pedicle,
or in the tunneled part of the flap.
Midface growth patterns have not been assessed in this
series and therefore cannot be commented. However, it
has been noticed that tension free complete two layer
closure of the palate and avoidance of radical dissection
in the maxillary tuberosity area are important factors
for avoiding disturbance in maxillary growth and
dentition.[1]
Buccal myomucosal flap is a dependable flap with well-
defined neurovascular supply. Bilayered total closure
of the palate without tension and raw area, proper
placement of reconstructed levator muscle sling, and
effective lengthening of soft palate are possible in the
repair of widest CP or large fistula. Knowledge of flap
anatomy and technique of flap transfer and its insetting
are required for success of this technique.
ACKNOWLEDGEMENT
I sincerely and respectfully acknowledge the help and support
given by Dr Ian T Jackson, Dr Mukund Reddy, Dr Prabha
16 January-June 2014 / Vol 1 / Issue 1
Yadav, and Dr Satish Arolkar. I appreciate Dr Nilesh Trivedi
and Dr Monali Mankadia for the help.
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3. Webster RC. Cleft palate II Treatment. J Oral Surg 1949;2:59-153,
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4. Spina V, Lodovici O, Pigossi N, Faiwichow I. Cleft palate elongation
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16. Freedlanders E, Jackson IT. The fate of buccal mucosal flaps in
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19. Kumar PA. The use of vomerine flap for palatal lengthening: The
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Cite this article as: Bhayani B. Buccinator myomucosal flap in cleft palate
repair: Revisited. J Cleft Lip Palate Craniofac Anomal 2014;1:11-6.
Source of Support: Nil. Conflict of Interest: None declared.
Journal of Cleft Lip Palate and Craniofacial Anomalies