CLINICAL REVIEW
Eisele, MD, Section Editor
Facial artery musculomucosal flap in head and neck reconstruction: A systematic
review
Tareck Ayad, MD, FRCSC,* Liyue Xie, MD
Division of Otolaryngology – Head and Neck Surgery, H^opital Notre–Dame and H^opital Maisonneuve–Rosemont, Universite de Montreal, Montreal, Quebec, Canada.
Accepted 29 April 2014
Published online 1 September 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23734
ABSTRACT: Background. The facial artery musculomucosal (FAMM)
flap has emerged as a popular option in head and neck reconstruction in
the last decade. The purpose of this study was to conduct a literature
review of the FAMM flap.
Methods. We have conducted a search on PubMed using specific key
words to identify all articles related to the FAMM flap. We reviewed the
modifications of the FAMM flap, its indications, contraindications, com-
plications, and outcomes.
Results. Thirty-eight articles published from 1992 to 2013 were included
for review. A total of 441 FAMM flaps were reported in the literature and
INTRODUCTION
Head and neck cancer ablation leads to complex defects
that require reconstruction in order to reestablish form
and function. A large spectrum of reconstructive options
exists depending on the nature and size of the defects:
skin grafts, locoregional pedicled flaps, and free flaps. In
recent years, the use of microvascular free flaps for
reconstructing such defects has been democratized in the
Western world. Harvesting free flaps is time-consuming
and also requires surgical expertise in microsurgery.
Small to medium-sized defects of the head and neck
can be successfully reconstructed using pedicled flaps
with limited morbidity to the donor site. Over the last
decades, the use of regional pedicled flaps, such as the
submental flap,1 the supraclavicular flap,2 or the facial
artery musculomucosal (FAMM) flap,3 has been increas-
ingly documented in the literature. The FAMM flap was
first described by Pribaz et al4 in 1992 and subsequent
publications developed new modifications and refined its
indications to make it an even more versatile intraoral
musculomucosal flap.
The FAMM flap should not be confused with the bucci-
nator musculomucosal flap described by Bozola et al,5
which is an intraoral flap pedicled on the buccal artery, a
branch of the internal maxillary artery. This flap is poste-
*Corresponding author: T. Ayad, Division of Otolaryngology – Head and Neck
Surgery, H^opital Notre–Dame, 1560 Sherbrooke Street East, Montreal, Quebec,
Canada, H2L 4M1. E-mail: tareck.ayad@umontreal.ca
David W.
the most commonly reconstructed site was the floor of the mouth. Func-
tional and aesthetic outcomes were judged to be excellent.
Conclusion. The FAMM flap is a versatile reconstructive option for small
and medium size defects in the head and neck. Recent studies have
explored new applications for this flap, such as in skull base recon-
struction. V
C 2014 Wiley Periodicals, Inc. Head Neck 37: 1375–1386,
2015
KEY WORDS: facial artery musculomucosal (FAMM) flap, facial
artery, musculomucosal flap, myomucosal flap, buccal mucosa
riorly pedicled with a more limited arc of rotation but a
larger width than the FAMM flap.
This review article is divided into 2 parts. The first part
focuses on the basics in anatomy and surgical technique
of this flap. The second part includes the different modifi-
cations in the surgical technique, current indications,
complications, and outcomes based on a systematic
review of the literature.
PART 1: GENERAL CONSIDERATIONS
Surgical anatomy
Facial vessels. The facial artery is a branch of the exter-
nal carotid artery exiting at the level of the neck. After a
cervical course, it passes from the medial side of the
mandible to its external side by grooving through the sub-
mandibular gland as it rounds the lower border of the
mandible. It follows a very tortuous pathway as it reaches
the internal canthus as the angular artery. With respect to
the buccal mucosa, it passes deep to the buccinator mus-
cle and superficial to the risorius, the zygomaticus
muscles, and the superficial lamina of the orbicularis oris
muscle. The facial artery has a variety of branching pat-
terns and terminal branches as reported in many studies.6–
10
According to the Lohn et al10 latest classification, the
final branches of the facial artery are as follows: type
I 5 angular; type II 5 lateral nasal; type III 5 alar; type
IV 5 superior labial; type V 5 inferior labial; and type
VI 5 undetected.
The frequency of the terminal branches of the facial
artery ending as the superior labial artery and that of the
HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015 1375
AYAD AND XIE
FIGURE 1. Schematic representation of the facial artery myomu-
cosal (FAMM) flap with extension to the periosteum of the mandi-
ble in a coronal cut through the cheek. 1: mucosa and
submucosa; 2: buccinator muscle; 3: facial artery; 4: motor
branches of the facial nerve; 5: mimic facial muscles; 6: inferior
gingivobuccal sulcus; 7: molar; 8: mandible; 9: periosteum; 10:
limit of the traditional FAMM flap (full line); and 11: modification
with extension to the mandibular periosteum (interrupted line).
Reproduced with the permission of John Wiley and Sons from the
article by Xie et al.17 [Color figure can be viewed in the online
issue, which is available at wileyonlinelibrary.com.]
terminal branches terminating past the alar base was,
respectively, 10% and 85% in the Lohn et al10 study, and,
respectively, 6.6% and 88% in the Koh et al7 study. Zhao
et al11 also demonstrated using Doppler ultrasonography
that the mean diameter of the facial artery was 2.6 mm at
the lower border of the mandible, 1.9 mm at the oral
commissure, and 1.6 mm under the nasal alar base. The
facial vein was almost always located posterior to the
facial artery.10 It starts at the internal canthus as the angu-
lar vein and becomes the facial vein as it runs down the
nasogenian fold. Near the mandible, the artery and vein
travel very close together and they diverge from each
other as they travel up toward the nose.11,12 The average
distance between them was found to be 13.6 mm at the
oral commissure and 16.3 mm under the nasal alar
base.11
Facial artery musculomucosal flap. The FAMM flap (Figure
1) is an intraoral cheek flap made up of mucosa, submu-
cosa, portion of the buccinator muscle, and the deeper
plane of the orbicularis oris muscle. It can be superiorly
pedicled on the angular artery with a retrograde flow or
1376 HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015
inferiorly pedicled with an anterograde flow on the facial
artery. The pivot point of the inferior FAMM flap is
located in the area of the last molar tooth and that of the
superior FAMM is at the gingival labial sulcus, or any-
where in between depending on the reconstructive needs.
The location of the defects will direct the use of either
the superiorly based or the inferiorly based FAMM flap.
The branches of the facial nerves lie deeper to the facial
artery and are usually not encountered during the harvest,
therefore, preventing facial paresis.
The width of the flap varies from 2.5 to 3 cm to allow
primary closure of the donor site. The facial vein is rarely
incorporated in the flap as the venous drainage is also
possible through a buccal plexus found in the submucosa
according to histologic studies achieved by Dupoirieux
et al.12 However, when the facial vein is not identified,
the pedicle base should be kept to at least 2 cm to ensure
an optimal venous drainage.
Surgical technique
Harvesting the inferiorly based facial artery musculomucosal
flap. The length of the flap is adjusted according to the
defect to be reconstructed. It can be longer if prolonged
higher in the gingivolabial sulcus but with a higher risk
of a random distal vascularization. The width of the flap
is usually around 2.5 cm from the base and gets thinner
distally. In this study, we describe our technique for har-
vesting the flap but variations exist in the literature.
Drawing the flap. An outline of the flap is marked on the
buccal mucosa respecting well-defined limits (Figure 2).
Anteriorly, the flap is drawn 1 cm posterior to the oral
commissure to avoid distortion of the labial commissure.
Posteriorly, the flap is limited by the orifice of the Sten-
sen’s duct. Inferiorly, the flap base is 2 to 3 cm large and
is centered over the area of the second and third molar.
The flap is designed over the facial artery trajectory with
FIGURE 2. Drawing of an inferiorly based facial artery myomu-
cosal (FAMM) flap on the left buccal cheek. The pedicle is at the
lower second and third molar tooth. The distal portion is located
at the superior gingivolabial sulcus. Reproduced with the permis-
sion of John Wiley and Sons from the article by Ayad et al.13
[Color figure can be viewed in the online issue, which is available
at wileyonlinelibrary.com.]

FIGURE 3. Donor site closure using buccal fat pad advancement.
Reproduced with the permission of Elsevier from the article by
Massarelli et al,14 V
C 2013. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]
an oblique orientation from the region of the second
molar to the ipsilateral gingivolabial sulcus superiorly. A
Doppler is sometimes used to confirm the location of the
facial artery but is not mandatory as the vessel will invar-
iably be found within the previously described anatomic
limits. The length of the flap is tailored proportionally to
the size of the defects.
Finding the facial artery. The first step of the harvest
requires identifying the facial artery, which can be done
with either one of the methods described below:
Distal identification of the facial artery. The distal part
of the flap is incised through the mucosa, submucosa, and
buccinator muscle. When the facial artery is found, it is
clipped and sectioned distally.
Anterior identification of the facial artery. The incision
is made at 1 cm posterior to the oral commissure through
the mucosa, submucosa, and the orbicularis oris muscle to
identify the superior labial artery. The latter is then fol-
lowed in a retrograde fashion leading to the facial artery.
Careful dissection often shows the “Y shaped” junction of
the 3 vessels (facial, superior labial, and nasal lateral
arteries) except when variations of the facial artery end
course is present. Ligation of the superior labial artery
should be performed only when the angular artery is
identified.
Flap elevation. The flap is harvested in a plane deep to
the facial artery by including the overlying part of the
buccinator muscle along its length and part of the orbicu-
laris oris in the area of the oral commissure. The facial
artery must be kept attached to the overlying tissues in its
entire length. During elevation, collateral vessels are
clipped and sectioned as the dissection progresses distal
to proximal. As mentioned previously, the venous drain-
age relies on a submucosal plexus and inclusion of the
FACIAL ARTERY MUSCULOMUCOSAL FLAP REVIEW
facial vein is not necessary. In the latter case, a 2 cm soft
tissue base must be maintained to allow adequate venous
drainage.
Harvesting the superiorly based facial artery musculomucosal
flap. Most of the steps in harvesting the inferiorly based
FAMM flap apply to the superiorly based FAMM flap.
The base of the superiorly based FAMM flap is located at
the superior gingival labial sulcus close to the alar mar-
gin, and, conversely, the distal portion of the flap lies at
the level of the retromolar trigone inferiorly.
If the superior labial artery is the terminal branch of
the facial artery, the FAMM flap could be based on it
instead of the angular artery, provided that the retrograde
flow is sufficient.
Closure of the donor site. The donor site can be closed pri-
marily if the flap is under 3-cm wide. If there is concern
about a potential contracture because of excessive tension,
the donor site can be skin grafted, left to granulate,13 or
closed with buccal fat pad advancement (Figure 3).14
Sectioning the pedicle. The pedicle can be safely sec-
tioned 3 weeks after the initial surgery, if needed. Pedicle
sectioning has been reported as early as 13 days postoper-
atively.13 Ayad et al13 reported the need for pedicle sec-
tioning in 67% of patients in one of their studies (38 of
57 patients). Indications include tethering of the tongue,
discomfort, or impairment of dental rehabilitation. Some
studies have reported modifications of the FAMM flap to
avoid 2-stage procedures.14,15 Refer to the section on
modifications of the FAMM flap for description of a 1-
stage procedure.
PART 2: LITERATURE REVIEW OF THE FACIAL
ARTERY MUSCULOMUCOSAL FLAP
METHODOLOGY
We conducted a search on PubMed on July 20, 2013,
using key words in all fields that are related to the
FAMM flap. Refer to Figures 4 and 5 for the search algo-
rithm. A total of 79 articles were retrieved using the
above search method. All these articles were reviewed in
details. Exclusion criteria were: FAMM acronym for
other meanings; other flaps (non-FAMM flaps); a review
or comment; and non-English or French articles.
Using the above exclusion criteria, 42 articles were
excluded. We scrutinized the citations of included articles
to identify additional relevant articles that could have
been missed by using the PubMed keywords search. Note
that articles classified as “buccinator flaps” have been
carefully reviewed because sometimes the terminology
“buccinator flap” was used to refer to the FAMM flap.
Therefore, 38 articles met the criteria for our review arti-
cle. Refer to Figure 2 for more details.
For outcomes related to flap survival and associated
complications, we only included articles with 10 or more
FAMM flaps. Articles with <10 flaps or cadaveric stud-
ies16,17 were also included in our review for issues per-
taining to modifications in the surgical technique, special
indications, or future directions.
HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015 1377
AYAD AND XIE
FIGURE 4. Search algorithm to retrieve all articles referring to facial
artery myomucosal (FAMM) flaps. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]
RESULTS
Note that the reported results were based on available
data only because not all articles provided detailed infor-
mation on every patient and every flap. The total number
of FAMM flaps reported so far in the literature was 485
(Table 1). When cadaveric studies were excluded, this
number fell to 441. There were 316 (69%) inferiorly based
flaps and 140 (31%) superiorly based flaps. The male-to-
female ratio was 4.2:1 (173 male and 41 female patients)
and their ages ranged from 18 months to 90 years.
All 38 included articles were case reports or case series.
Articles were published from 1992 to 2013 with a signifi-
cant trend toward an increasing number of articles pub-
lished each year over the last 2 decades (Figure 6).
Facial artery musculomucosal flap modifications
Single-stage procedure. A 2-stage procedure to section
the pedicle is needed in up to 62% of patients who had a
FAMM flap for floor of mouth (FOM) reconstruction.13
Attempts have been made to minimize the need for a
second-stage procedure. Duranceau and Ayad15 presented
a modification of the surgical approach of the FAMM
flap to allow a 1-stage procedure with favorable surgical
outcomes in 3 patients. The modification consisted of
using the pedicle to fill the posterior part of the FOM
defect by extending the anterior incision over the alveolar
crest in order to reach the FOM defect. The base of the
flap is then dissected subperiosteally over the alveolar
crest and is used to cover the posterior FOM defect as
well as the alveolar crest (Figure 7).
Another modification of a single-stage procedure was
described by Massarelli et al14 as the tunnelized island
FAMM flap (see below).
Extending the size of the flap.
The width. The reconstructive potential of the FAMM
flap is restricted by its relative small width of 3 cm wide
1378 HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015
to allow primary closure of the donor site. Its posterior
extension is limited by the opening of Stensen’s duct.
O’Leary and Bundgaard18 successfully overcame this
problem in 4 patients by developing a posterior flap
extension with the inclusion of the parotid papilla. The
parotid duct is cut during flap elevation and the new
opening is sutured to the mucosa before the donor site is
closed. The authors also proposed to mobilize the buccal
fat pad into the donor site and to suture it around the
edge of the defect.18–21 The buccal fat pad then re-
epithelializes during the healing process to give satisfac-
tory results.
The length. The length of the flap is usually sufficient
to fill ipsilateral oral cavity defects even if they partially
extend on the contralateral side. To reconstruct defects
that extend further, some authors have proposed exten-
sions to the traditional FAMM flap. In a case of soft pal-
ate defect causing velopharyngeal insufficiency and nasal
regurgitation, Dolderer et al22 have extended a superiorly
based FAMM flap to a paralyzed lower lip “islanded” on
the inferior labial artery to reconstruct the palatal defect.
This modification allowed reconstructing a full thickness
defect of the soft palate with suitable trilaminar mucosa
muscle skin tissue, with improvement in speech and swal-
lowing, resolution of nasal regurgitation, and dribbling
from the paralyzed lower lip.
In a cadaveric study, Xie et al17 harvested superiorly
based FAMM flaps with extensions to the mandibular
periosteum (Figure 1) to increase their reach for skull
base defect reconstructions. In this study, the mean length
of the flap was 8.82 cm and, when combined with the
extension flaps, it brought an additional 2.39 cm in
length. However, the viability of these extensions cannot
be confirmed as no clinical case has been reported yet.
Arterialized facial artery musculomucosal island flap and tunnel-
ized island facial artery musculomucosal flap. The arterial-
ized facial artery musculomucosal island flap (a-
FAMMIF; Figure 8) is a FAMM flap pedicled solely on
the facial artery as the soft tissues around the pedicle are
fully dissected and divided. According to the authors who
developed this modification, the venous return is based
on the venae comitantes, which are present in the collar
of fat around the facial artery. This modification extended
FIGURE 5. Algorithm to select relevant articles for review. [Color
figure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]
 FACIAL ARTERY MUSCULOMUCOSAL FLAP REVIEW

TABLE 1. List of all articles included for review.

Article number
ordered by year Authors (publication year) No. of flaps Superior pedicle Inferior pedicle

1 Pribaz et al. (1992) 18 8 10

2 Uglesić et al (1995) 14 0 14
3 Abou Chebel et al (1998) 10 0 10
4 Duffy et al (1998) 2 2 0
5 Dupoirieux et al (1999) 6 3 3
6 Fassio et al (1999) 5 3 2
7 Pribaz et al (2000) 16 11 5
8 Hatako et al (2002) 1 0 1
9 Ashtiani et al (2005) 22 8 14
10 Heller et al (2005) 6 6 0
11 Joshi et al (2005) 17 2 15
12 Ceruse et al (2006) 40 0 40
13 Lahiri et al (2007) 16 16 0
14 Ninkovik et al (2007) 3 3 0
15 Albert et al (2008) 1 0 1
16 Ayad et al Floor of mouth (2008)* 61 0 61
17 Ayad et al Harvesting technique 107 7 100
and indications (2008)*
18 Baj et al (2008) 1 0 1
19 Massarelli et al (2008) 1 0 1
20 Baj et al (2009) 1 N/A N/A
21 Bianchi et al (2009) 27 N/A N/A
22 Mebeed et al (2009) 4 0 4
23 Wolber et al (2009) 20 0 20
24 Matros et al (2010) 1 0 1
25 Ninkovik et al (2010) 1 0 1
26 Rivera–Serrano et al (2010) 18 18 0
27 Selber et al (2010) 1 0 1
28 Dolderer et al (2011) 1 1 0
29 Duranceau et al (2011) 3 0 3
30 O’Leary et al (2011) 22 6 16
31 Gurunluoglu et al (2012) 2 2 0
32 Khanna et al (2012) 1 0 1
33 Massarelli et al (2012) 1 0 1
34 Bonawitz et al (2013) 6 6 0
35 Massarelli et al (2013) 52 4 48
36 Massarelli et al (2013) Free flap 1 N/A N/A
37 Shetty et al (2013) 11 8 3
38 Xie et al (2013) 26 26 0
Total 485 140 316

Abbreviation: N/A, not available.

* These 2 studies come from the same author and have the same cohort of patients. Only the article Ayad et al. Harvesting technique and indications (2008) is considered for calculating the total
number of flaps.

the reach of this flap and avoided further second-stage
surgery for division of the vascular and mucosal pedicle,
as well as vestibuloplasty.21
The arterialized facial artery myomucosal island flap
(a-FAMMIF) was described as early as 1995 by Uglesić
and Virag.24 Although they did not give this name, the
principle of the island flap remains the same. The authors
modified the surgical technique with an extraoral incision
in the nasolabial fold to simplify facial artery dissection
as they associated the higher rate of flap necrosis to the
skeletonization of the facial artery through the intraoral
approach.
Massarelli et al14,19,21 also used a modified FAMM flap
for oral cavity and soft palate reconstruction. The FAMM
flap was designed in a bilobed or trilobed fashion and
was raised following the buccopharyngeal fascia by
including the facial artery and its buccal branches and the
facial vein. A blunt dissection of the facial vessels from
the surrounding cheek tissues were carried on to release
the flap, which is then tunnelized to the neck through a
paramandibular tunnel. This became an island flap and
was transferred to the oral cavity or the oropharynx
through a tunnel in the FOM routing the pedicle under
the mandible. This technique can also be categorized as a
single-procedure modification because there is no need
for a secondary surgical procedure to section the pedicle
or perform a vestibuloplasty. The drawback of this modi-
fication is a possible higher risk of marginal mandibular
branch palsy because a wide dissection of the facial pedi-
cle is required through a narrow tunnel of the cheek.
Massarelli et al19 had first published this modification
under the term of buccinator myomucosal island flap and
then under the name of tunnelized-facial artery myomu-
cosal island flap (t-FAMMIF).14

HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015 1379

AYAD AND XIE

reported that 14 of 22 patients in their study have under-

gone prior or concurrent neck dissection and did not
show a higher rate of flap complications. They stated that
as long as the facial artery was kept intact during neck
dissection, a FAMM flap can be raised as usual. Massar-
elli et al21 confirmed this statement when he successfully
harvested FAMM flaps in 39 patients who underwent
neck dissection for oncologic indications.
In an anatomic study, Park et al23 showed that terminal
end branches of the facial artery anastomosed with those
from the contralateral side through a vertical and a hori-
zontal vascular network. According to this study, even if
the ipsilateral facial artery was previously severed during
a neck dissection, a FAMM flap from the same side could
still be theoretically raised with its vascularization based

FIGURE 6. Trends of publication of facial artery myomucosal

(FAMM) flap articles. [Color figure can be viewed in the online
issue, which is available at wileyonlinelibrary.com.]

Composite facial artery musculomucosal flap. As mentioned

earlier, a soft palate defect was successfully reconstructed
using a trilaminar structure in the form of a redundant
lower lip by Dolderer et al.22 A variant of the composite
FAMM flap termed “composite FAMM free flap” was
used in a patient with through-and-through cheek defect
for reconstruction of ballistic facial trauma.21

Free facial artery musculomucosal flap. The only case report

of a free FAMM flap (Figure 9) was published by Mas-
sarelli et al25 who described the use of a free FAMM flap
in contralateral cheek mucosa reconstruction. The flap
was harvested by including the facial artery and vein and
the pedicle was severed to allow use of the FAMM flap
as a free flap. In this case report, the patient underwent
postoperative radiation therapy with maintained flap bulk
and excellent aesthetic results.

Indications
FAMM flaps have been widely used for small and
medium size defects of primarily the oral cavity and other
head and neck regions. Their clinical applications are
diverse. They are mostly used to reconstruct defects from
tumor ablation, but other indications include repair of cleft
palate, septal perforation, and osteoradionecrosis. Table 2
is an exhaustive list of indications of the FAMM flap and
its frequency of use reported in the literature so far.
Table 3 illustrates the different sites and subsites recon-
structed by the FAMM flaps and their respective frequen-
cies of use. When the different subsites and sites were FIGURE 7. Modification for single stage procedure (A) Traditional
combined, 96.3% of FAMM flaps were used for recon- inferiorly based facial artery myomucosal (FAMM) flap in the
struction of oral cavity and oropharynx, the most frequent reconstruction of floor of mouth (FOM) defect with the pedicle
subsite being the FOM (39.9%; Figure 10). bridging over the alveolar crest. (B) Modified 1-stage procedure
of the inferiorly based FAMM flap with the base of the pedicle
dissected subperiosteally over the alveolar crest and covering the
Contraindications defects of the alveolar crest and the FOM. Reproduced with the
Neck dissection. Bianchi et al26 contraindicated the use permission of John Wiley and Sons from the article by Duranceau
and Ayad,15 VC 2011.
of the FAMM flap in a previously dissected neck. This
opinion was rejected by O’Leary and Bundgaard18 who

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 FACIAL ARTERY MUSCULOMUCOSAL FLAP REVIEW

FIGURE 8. Tunnelized facial artery myomucosal island flap (t-FAM-

MIF). The islanded FAMM flap is routed medially to the mandible to
reconstruct an oral cavity defect. Reproduced with the permission
of Elsevier from the article by Massarelli et al,14 V
C 2013. [Color

figure can be viewed in the online issue, which is available at

wileyonlinelibrary.com.]

on the contralateral facial artery through the inferior

labial or mental arteries.
These anatomic findings in cadavers were clinically
confirmed in the study of Ayad et al13 in which 4 viable
inferiorly based FAMM flaps were raised in patients with
previously ligated facial arteries. All flaps survived with
the exception of one that experienced distal necrosis with
no revision surgery needed. The authors, however, recom-
mended using an alternative method of reconstruction in
this context.
FIGURE 9. The free facial artery myomucosal (FAMM) flap with
the facial artery and vein attached. Reproduced with the permis-
sion of John Wiley and Sons from the article by Massarelli et al,25
C 2013. [Color figure can be viewed in the online issue, which is
V
available at wileyonlinelibrary.com.]
TABLE 2. Indications for the facial artery myomucosal flap.

No. of FAMM
Preoperative radiation therapy. In the O’Leary and Bundg- Indications flaps %
18
aard study, 4 patients had received preoperative radiation
therapy and all of them experienced postoperative flap Defects post tumor ablation 306 70.7
complications. These included trismus, bleeding because of Cleft palate 55 12.7
manipulation by patient, local dehiscence, and osteoradio- Osteoradionecrosis 28 6.5
necrosis. The authors attributed their high complication Trauma with defects other than 17 3.9
septum (MVA, gunshot, bite, fall)
rate of 32% (7 of 22 flaps) to the inclusion of previously
Arteriovenous malformation 14 3.2
irradiated patients in their study. Another study with 61 Nasal perforation (blunt trauma, 8 1.8
flaps showed a higher complication rate (36% overall) than cocaine abuse, submucosa
the average rate reported in the literature. In this study, 10 resection, Wegener
patients were previously irradiated, but the authors did not granulomatosis)
report the specific complication rate of this subgroup.13 Iatrogenic (tooth extraction) 2 0.5
Other authors reported a failure rate of 5% attributed to Buccal mucosa contracture release 2 0.5
facial artery thrombosis secondary to preoperative radiation Facial microsomia (lip) 1 0.2
therapy and/or neck dissection. According to these authors, Total* 433 100
these complications can be avoided by preoperative use of
a Doppler to confirm facial artery blood flow.20 Abbreviations: FAMM, facial artery myomucosal; MVA, motor vehicle accident.
* The total number of FAMM flaps in this table is applicable only for available data in the
Previous radiation therapy is therefore not an established literature.
contraindication to the use of the FAMM flap. There is a Note that cadaveric studies have been excluded.

HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015 1381

AYAD AND XIE
TABLE 3. Sites of reconstruction.
Site No. of FAMM flaps
Floor of mouth 182
Palate 95
Alveolar ridge 60
Lip 46
Oropharynx 25
Tongue 20
Nose 15
Buccal mucosa 7 1.5
Retromolar trigone 4 0.9
Orbit 2 0.4
Total 456
Abbreviations: FAMM, facial artery myomucosal.
Note that cadaveric studies have been excluded.
lack of data to make a strong recommendation against the
use of the FAMM flap in previously irradiated patients.
Other contraindications. One author discouraged the use of
the FAMM flap when diffuse dysplasia of the oral cavity
was present.18 Some authors recommended infiltration of
the incision lines with 1% lidocaine and epinephrine,3
whereas others contraindicate its use because of the
potential risk of arterial spasms or hematoma formation.21
Complications
We decided to only include articles with at least 10
patients per study in order to decrease the risk of selec-
tion bias. It is difficult to bring a thorough discussion on
the complications associated with the FAMM flaps for
various reasons (Table 4).
First, only 14 articles have mentioned flap complica-
tions. Moreover, in some studies, there were a mixture of
FAMM flaps, buccinator flaps, and other flaps, but the
complication rate was given as an overall rate. Therefore,
we could not subtract data specific to the FAMM flaps.
Also, only a few studies systematically reported the rele-
vant information for each complicated flap, such as the
technique of harvest, the size or site of the reconstructed
defect, the perioperative complications, etc. Therefore, for
most of the studies, it was impossible to determine under
what circumstances a FAMM flap showed a higher rate
of dehiscence or higher rate of necrosis.
A total of 376 FAMM flaps were analyzed for compli-
cations. Of these, 46 flaps (12.2%; range, 0% to 25%)
had partial necrosis (Figure 11) and 11 flaps (2.9%;
range, 0% to 12.5%) had complete necrosis. Other com-
plications included dehiscence, venous congestion, hema-
toma, and infections, and they were found in 48 flaps
(12.8%; range, 0% to 100%).
In the study by Ayad et al,13 the complication rate of
partial necrosis was higher in secondary reconstruction
procedures compared with flaps used in primary recon-
struction (37.5% and 20%, respectively) and higher in
reconstruction for T3 to T4 primary tumors compared
with flaps used for T1 to T2 primary tumors (44% and
18%, respectively). Unfortunately, the details of each
complicated flap were not provided. The authors were
1382 HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015
%
39.9
20.8
13.2
10.1
5.5
4.4
3.3
100
FIGURE 10. Facial artery myomucosal (FAMM) flap for reconstruc-
tion of floor of mouth (FOM) defect. A left inferiorly based FAMM
flap is used to partially reconstruct the left tongue at FOM defect.
The donor site was closed primarily. Reproduced with the per-
mission of John Wiley and Sons from the article by Ayad et al,13
C 2008. [Color figure can be viewed in the online issue, which is
V
available at wileyonlinelibrary.com.]
able to observe that trend because they had a big cohort
of patients, which was not possible in all the other studies
translating into case reports and small case series.
Venous congestion. Venous congestion was found in 21
flaps (5.6%), but all the flaps were successfully managed
with conservative treatment. Among these, 17 flaps came
from the same case series by Joshi et al.27 In this study,
all the flaps were used for oral cavity defect reconstruc-
tions after cancer ablation. All the flaps were harvested
according to the standard anatomic landmarks, and all the
flaps, with the exception of 2 flaps, were island flaps.
Almost all the flaps developed varying degrees of venous
congestion within 4 to 6 hours postoperatively, but settled
on their own within 24 to 48 hours. The indications and
sites of reconstruction of the flaps used in this study were
comparable to those from other studies. Risk factors for
developing venous congestion remain unclear, but may
include factors such as the surgical technique, a small
pedicle, and absence of a facial vein (see below a-
FAMMIF).
Arterialized facial artery musculomucosal island flap and
tunnelized-facial artery myomucosal island flap. Some
authors characterized the FAMM flap as “arterialized”
rather than axial because the facial vein is not always
incorporated as a part of the FAMM flap. For that reason,
in the absence of the facial vein, it is suggested that the
pedicle base be kept at a minimum of 2 cm to ensure
adequate venous drainage through the submucosal venous
plexus.3 With the advent of new modifications, such as
the a-FAMMIF, the pedicle base is sometimes fully sec-
tioned.21 We can then question the viability and the com-
plications of these flaps. There was a total of 76 a-
FAMMIFs in the literature (Table 5).21,24,27After remov-
ing these cases from Table 4, the complication rate for
the a-FAMMIF was compared to that of the remaining
 FACIAL ARTERY MUSCULOMUCOSAL FLAP REVIEW

TABLE 4. Complications of facial artery myomucosal flaps.

Flap necrosis Other complications

Article number Articles No. of flaps Partial Complete Type Treatment

1 Pribaz et al (1992) 18 2 1 N/A N/A

2 Uglesić et al (1995) 14 0 0 1 wound dehiscence N/A
3 Abou Chebel et al 10 0 0 N/A N/A
(1998)
4 Ashtiani et al (2005) 22 2 1 N/A N/A
5 Joshi et al (2005) 17 1 0 All developed venous All resolved within
congestion 24–48 h
6 Ceruse et al (2006) 40 0 4 4 dehiscence or Conservative
delayed scarring
7 Lahiri et al (2007) 16 2 2 N/A N/A
8 Wolber et al (2008) 20 1 0 2 labial contracture N/A
6 trismus Self-resolved
9 Ayad et al Floor of 61 15 0 3 infections 1 surgical abscess
mouth (2008)* drainage
1 hematoma Surgical drainage
3 tongue tethering 1 surgical release
1 trismus Surgical release
10 Ayad et al Harvesting 107 17 1 N/A N/A
technique and indi-
cations (2008)*
11 Bianchi et al (2009) 27 1 1 N/A N/A
12 O’Leary et al (2011) 22 3 0 1 trismus N/A
1 bleeding Facial artery
ligation
1 osteoradionecrosis N/A
1 integration failure Replaced with a
temporal flap
13 Massarelli et al 52 0 1 2 venous congestion Self-resolved with
Cheek mucosa 72 h
(2013)
1 salivary fistula Conservative
14 Shetty et al (2013) 11 2 0 2 venous congestion Resolved within
48 h
1 dehiscence Resutured
Total 376 46 (12.2%) 11 (2.9%) 48 (12.8%) N/A

Abbreviation: N/A, not available.

* These 2 studies come from the same author and have the same cohort of patients. The article Ayad et al. Floor of mouth (2008) was included in this table for reference purposes because of the
exhaustive list of complications. The article Ayad et al. Floor of mouth (2008) was not considered for calculating the total number of flaps.
Note that cadaveric studies have been excluded.

FIGURE 11. Distal partial necrosis of the facial artery myomucosal
(FAMM) flap that was used in the reconstruction of a floor of
mouth (FOM) defect. [Color figure can be viewed in the online
issue, which is available at wileyonlinelibrary.com.]
flaps. The rate of total necrosis and that of the other com-
plications, including venous congestion and wound dehis-
cence, was much higher for the a-FAMMIF, 5.3% (vs
1.9%) and 29% (vs 7.6%), respectively. However, the a-
FAMMIF presented a lower rate of partial necrosis (1.3%
vs 14.3%) compared with the other FAMM flaps. We
cannot conclude with certainty that the a-FAMMIF has a
higher complication rate of total necrosis, venous conges-
tion, or wound dehiscence than the other types of FAMM
flaps because the complications were not reported homo-
geneously in most of the studies.
The t-FAMMIF, as opposed to the a-FAMMIF, is based
on both the facial artery and the facial vein. Analysis of
the complications for this particular flap is very limited
because of the small number of cases in the literature.
Moreover, this type of modification was described by a
single author.14,19,21 There were a total of 19 flaps with 1
case of total necrosis secondary to accidental resection of
the facial vein.21

HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015 1383

TABLE 5. Complications of arterialized facial artery myomucosal island flaps.

Flap necrosis

Articles No. of a-FAMMIF flaps Partial Complete Other complications

1 Uglesić et al (1995) 14 0 0 1 wound dehiscence

2 Joshi et al (2005) 17 1 0 All developed venous congestion
3 Ceruse et al (2006) 40 0 4 4 dehiscence or delayed scarring
4 Massarelli et al Cheek 5 0 0 0
mucosa (2013)
Total 76 1 (1.3%) *14.3% 4 (5.3%) *1.9% 22 (29%) *7.6%

Abbreviation: a-FAMMIF, arterialized facial artery myomucosal island flap.

* Complication rate calculated for the flaps after exclusion of the a-FAMMIF.

FIGURE 12. A 2-year-old girl with an acci-

dentally excised three-fourths of the lower-
lip vermillion. (A) Preoperative view. (B)
Facial artery myomucosal (FAMM) flap
marking. (C) Harvesting of the flap. (D)
Suture of the flap. (E) Result 20 days after
the first surgery. (F) Immediate result after
the second surgery after sectioning the
FAMM pedicle and cheiloplasty. (G) Aes-
thetic result 14 months later. Reproduced
with the permission of John Wiley and Sons
from the article by Massarelli et al,21 V C

2013. [Color figure can be viewed in the

online issue, which is available at wileyonli-
nelibrary.com.]

TABLE 6. Advantages and disadvantages of the facial artery myomucosal flap.
Advantages
 No external scar
 Big axis of rotation and great length for reaching
big range of reconstruction sites
 Thin and pliable
 Mucosal flap for replacement of mucosal tissue
defect (absence of hair and function in lubrication)
 Easy to harvest
 Many modifications described
 Reliable flap with a strong vasculature that withstands
postoperative radiation therapy13
 Low complication rate
 Superior (retrograde flow) or inferior (anterograde) based
depending on reconstructive sites
 Length can be tailored to defects
 Primary closure of donor site if width under 3 cm
 Flap harvest and tumor ablation in the same operating field
 Previous radiation therapy in the field of the flap is not a
contraindication for flap use13,18,20
 No retraction even postradiation therapy20,21
 Previous neck dissection is not a contraindication
* Modifications exist to widen the flap by rerouting the Stensen’s duct.18
†
Modifications exist to avoid a second procedure to section the pedicle.14,15,19
Outcomes
Postoperative diet. Outcome data were inconsistently
recorded in all the articles. There were 22 articles that
mentioned postoperative diet. Oral food intake started
most often 1 week after the surgery but ranged from post-
operative day 1 to day 13. Most patients resumed a nor-
mal diet during follow-up. When the FAMM flap was
used for reconstruction of the cleft palate, 81% of these
patients had resolution of nasal regurgitation.
Speech. Data for speech were available in 18 studies.
Ayad et al13 reported that 93% of patients had functional
or understandable speech when a FAMM flap was used
for FOM defect reconstruction. Most studies that reported
a FAMM flap for palatal fistula reconstruction showed
improved velopharyngeal function.
Aesthetic. Data concerning the aesthetic results (Figure
12) after the use of the FAMM flap were available for 14
studies. The presence of an external scar and permanent
cheek deformity was only reported in 1 study, which
described a variation in flap harvest using incisions in the
nasolabial fold.24 This variation was reported in the early
days of the FAMM flap and was not popularized afterward.
Other studies showed excellent aesthetic results.28–30 Tem-
porary facial paralysis occurred in 3 cases and resolved
within 2 months.21 However, the article included both
FAMM flaps and buccinator flaps and the authors did not
specify in which group the facial paralysis occurred. Per-
manent facial paralysis was not reported in the literature.
Advantages and disadvantages
The advantages of the FAMM flap greatly outnumber
its disadvantages (Table 6). In recent studies, new modifi-
FACIAL ARTERY MUSCULOMUCOSAL FLAP REVIEW
Disadvantages
 Limited width*
 Use of a bite block after surgery to avoid biting
the pedicle in dentate patients
 Two-stage procedure required to section the pedicle in dentate patients†
 Bulky flap that may hinder use of dental prosthesis
if used in vestibular reconstruction
cations have been developed to eliminate some limitations
of this flap in order to make it into one of the most versa-
tile intraoral flaps.
Future directions: Reconstruction of the skull base
The number of articles reporting the use of the FAMM
flap for head and neck defect reconstructions have grown
rapidly in recent years (Figure 6). A new potential recon-
struction site is the skull base. Two studies have explored
the possibility of skull base reconstruction using the supe-
riorly based FAMM flap.16,17 In the cadaveric study con-
ducted by Rivera–Serrano et al,16 the flaps were referred
to as “pedicled facial buccinator flaps” and were har-
vested with and without the mucosa. They investigated
many maxillary osteotomies for transposing the flaps
across the nasal cavity, which were, in turn, transferred to
the skull base. It was shown that the flaps reliably
reached the anterior skull base and the planum
sphenoidale.
Xie et al17 harvested 26 FAMM flaps in cadavers,
among which some included extensions with mandibular
periosteum. These extensions are newly developed mod-
ifications that elongated the traditional FAMM flaps by
an average of 2.39 cm. This extra length can be folded
on the distal portion of the FAMM flap and used as a
multilayer reconstruction for the anterior skull base or
can offer a tension-free coverage of the more posterior
skull base defects. The FAMM flaps were shown to eas-
ily reach the frontal sinuses, the fovea ethmoidalis, the
sella turcica, and the planum sphenoidale. Although
promising, no live case of skull base reconstruction with
the FAMM flap has been reported yet. The viability of
the extensions described by this study needs further
investigations.
HEAD & NECK—DOI 10.1002/HED SEPTEMBER 2015 1385
AYAD AND XIE
CONCLUSION
The FAMM flap is a versatile reconstruction option for
small and medium sized defects of the oral cavity, oro-
pharynx, lips, nasal septum, and other less commonly
exploited sites. The advantages of this pedicled intraoral
flap considerably outweigh its disadvantages. Many modi-
fications have been recently developed to increase the
width, the length, or to avoid a 2-stage procedure, there-
fore expanding the scope of use of this flap. Care should
be taken when considering using the a-FAMMIF modifi-
cation for reconstruction as there is a possible trend
toward a higher complication rate of total necrosis and
venous congestion. New studies are exploring new indica-
tions and applications of this flap and results are very
promising so far for its use in skull base reconstruction.
This flap holds great potential in many aspects and is
worth further investigational studies. Future studies
should focus on higher levels of evidence studies than
case reports and case series.
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