Original Research—Facial Plastic and Reconstructive Surgery
Otolaryngology–
Buccinator Myomucosal Flap for
Reconstruction of Glossectomy Defects
Seung Hoon Woo, MD1,2*, Han-Sin Jeong, MD3*,
Jin Pyeong Kim, MD1, Jung Je Park, MD1, Junsun Ryu, MD4, and
Chung-Hwan Baek, MD3
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. The use of the myomucosal flap from the buccina-
tor muscle is a valuable reconstruction method for intraoral
defects. We report the clinical advantages and pitfalls of
using the buccinator myomucosal flap for tongue recon-
struction after intraoral resection of tongue cancer.
Study Design. Prospective study.
Setting. University hospital.
Subjects and Methods. We used buccal artery–based buccina-
tor myomucosal flaps for tongue reconstruction in 11 partial
or total edentulous patients who underwent resection of
tongue cancer. The size and site of the tongue defect ranged
from one-third to one-half of the tongue in the lateral
border. We analyzed the clinical features and oncologic and
functional outcomes to define adequate indications.
Results. All flaps were successfully harvested and transposed,
and the donor sites were primarily closed. The pedicles
were safely divided 2 to 3 weeks postoperatively. In 8 of 11
patients, concurrent upper neck dissection was performed
without compromising blood supply to the flap. The range
of tongue motion and the volume of the reconstructed
tongue were satisfactory, and the patients experienced no
difficulties in swallowing or speech.
Conclusion. Particularly in edentulous patients, the buccal
myomucosal flap can be a good option for reconstructing
partial tongue defects after cancer surgery.
Keywords
tongue neoplasm, surgical flaps, reconstruction, edentulous
Received January 5, 2013; revised March 21, 2013; accepted April 3,
2013.
O
ral cavity defects resulting from oncologic resection
can be reconstructed using several methods, depending
on the size and site of the defect. Radical resection of
malignant tongue tumors may lead to severe morphologic and
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Head and Neck Surgery
149(2) 226–231
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2013
Reprints and permission:
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DOI: 10.1177/0194599813487492
http://otojournal.org
functional defects.1-12 Currently, extensive resections
involving the tongue are usually approached using free
flaps, which provide the best results in terms of form and
function.13,14 Small defects are primarily sutured or left
alone for natural healing.
Although free flaps are considered the best option for
tongue defects, the use of free flaps is also accompanied by
several disadvantages in terms of donor site morbidity; the
need for lengthy, complex surgery; and the replacement of
oral mucosa with skin-lining tissue.
Intraoral mucosa is distinguished by mucus production
with a high cell renewal rate and minimal scar formation.
Buccinator myomucosal flap use was originally introduced
to repair small mucosal defects of the oral cavity and in the
neck region.15,16 Although the buccinator myomucosal flap
has the advantage of restoring the mucosal lining over the
defect, use of the buccinator myomucosal flap for recon-
struction after partial glossectomy is not widespread.
An anatomic study on the buccinator muscle was pub-
lished by Zhao et al in 1999.17 The buccinator muscle is a
thin, quadrilateral muscle in the cheek. It originates from
the outer surfaces of the alveolar processes of the maxilla
and mandible. Posteriorly, it arises from the pterygomandib-
ular raphe. Anteriorly, it inserts into the orbicularis oris
muscle. Laterally, it is related to the ramus of the mandible,
the masseter and medial pterygoid muscles, the buccal fat
pad, and the buccopharyngeal fascia. Medially, it is covered
by the submucosa and mucosa of the cheek. It forms part of
1
Department of Otorhinolaryngology–Head and Neck Surgery, Gyeongsang
National University, Jinju, South Korea
2
Institute of Health Sciences, Gyeongsang National University, Jinju, South
Korea
3
Department of Otorhinolaryngology–Head and Neck Surgery, Samsung
Medical Center, Sungkyunkwan University School of Medicine, Seoul, South
Korea
4
Head and Neck Oncology Clinic, National Cancer Center, Ilsan, South
Korea
*These authors contributed equally to this work.
Corresponding Author:
Seung Hoon Woo, MD, Department of Otorhinolaryngology–Head and
Neck Surgery, Gyeongsang National University Hospital, 90 Chilam-dong
Jinju South Korea, 660-702.
Email: lesaby@hanmail.net
Woo et al
Figure 1. Anatomic relationship with the buccinator myomucosal
flap. Ba, buccal artery; Fa, facial artery; Ib, inferior branch of facial
artery; Io, infraorbital artery; nvp of pbf, neurovascular pedicle of
posteriorly based flap; Pd, parotid duct; Pb, posterior branch of
facial artery; Ma, maxillary artery.
the pharyngeal-buccal-orbicularis sphincter system and
functions to facilitate whistling, sucking, propelling food
during mastication, and voiding the buccal cavity.18
The muscle is supplied with blood through the facial
artery, which enters the face and courses on the surface of
the buccinator. The buccal artery, a branch of the internal
maxillary artery, also supplies the muscle. The buccal artery
with a neurovascular pedicle posteriorly supplies the bucci-
nator muscle (Figure 1).
The venous drainage departs from the buccal and facial
artery around the oral commissure, courses along the poster-
ior end of the buccal muscle, and drains into the pterygoid
plexus and the internal maxillary vein through the buccal
vein (concomitant to the buccal artery). Finding the course
and drainage of the buccal artery and vein is useful for har-
vesting the flap and for vascular pedicle dissection.
Other investigators had previously presented reconstruc-
tion of the tongue using a buccinator myomucosal flap
based on the facial artery.16 However, this flap had a limita-
tion in neck dissection patients because neck dissection had
the potential to cause damage to the facial artery. Therefore,
we use a buccinator myomucosal flap based on the buccal
artery for tongue reconstruction after tongue resection with
neck dissection.
We describe a procedure that uses the buccinator myo-
mucosal flap for partial tongue defects in partial or total
edentulous patients on a pedicled blood supply based on the
buccal artery. Herein, the detailed surgical technique and
subjective and objective outcomes (mouth opening, speech,
swallowing, volume of the flap, and mobility of the tongue)
in our case series are presented.
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227
Methods
Subjects
This prospective clinical study was approved by the
Institutional Review Board, Gyeongsang National Medical
School, Jinju, Korea. Between January 2010 and December
2010, 11 partially edentulous patients with squamous cell
carcinoma underwent reconstruction of partial glossectomy
defects (the tongue defect was not more than half and did
not extend to the floor of the mouth) using buccinator myo-
mucosal flaps (Table 1). The patients’ ages ranged from 49
to 82 years. Reconstruction was performed immediately
after resection in all patients. Two or 3 weeks after surgery,
the pedicle of each buccinator myomucosal flap was divided
with an ultrasonic dissector. All patients were followed up
for at least 12 months (mean, 18 months).
Twelve months after the surgery, mouth opening, speech,
swallowing, tongue mobility, and flap volume were evalu-
ated. For mouth opening, the preoperative and postoperative
(after 12 months) vertical lengths were compared. The
length was calculated between the upper and lower incisors.
The speech evaluation included a sentence articulation test
to identify correct and incorrect consonant articulation. The
articulation test involved a standard clinical procedure using
the Fisher-Logemann Test of Articulation Competence.19
This test can be used as a screening and diagnostic tool of
articulatory errors and consisted of a picture and sentence
test. Results were compared with patients’ scores both
before and after surgery. Evaluation of the swallowing func-
tion was based on patient interviews conducted 12 months
after surgery. Parameters reported by patients were assigned
a score ranging from 0 to 10. The range of tongue lateral
motion was compared between the normal side and the flap
side. When the tongue mobility in the normal side was
assumed as 100%, the flap tongue mobility was calculated
as a percentage of normal tongue mobility. The flap
volumes were recorded at 1 month and 12 months post-
operatively by neck computed tomography (CT) scan. The
length, width, and height were measured by neck CT scan
and the flap volume was calculated. (Flap volume = p/6 3
length 3 width 3 height.)
Surgical Procedure
The transposition of the flap was planned as illustrated in
Figure 2. Selective neck dissection was done (levels I, II,
and III). The margins of the flap were drawn with a surgical
pen, taking care to avoid the parotid duct opening at the
flap’s superior margin (Figure 2). The shape and size of
the flap depended on the shape of the tongue, which had
been resected. The anterior limit was the oral commissure
and the posterior limit was the pterygomandibular raphe.
The inferior limit of the flap depended on what operation
was planned. In our cases, the distance between the superior
and inferior margin of the flap was not more than 4.0 cm;
therefore, the donor site defect could be primarily sutured.
After incising the buccal mucosa and muscle along the
upper and anterior borders, the flap was elevated generally
228 Otolaryngology–Head and Neck Surgery 149(2)

Table 1. List of tongue cancer patients, sites, tumor staging, surgical procedures, and complications.
Surgery

Cancer Operation Operation Defect Flap Adjuvant Follow-up,

Patient No. Age, y/Sex Stage Name Time, min Size, cm Size, cm Treatment mo Status Complication

1 49/M T1N0M0 PG 30 235 3 3 5.5 None 15 NED None

2 59/M T1N0M0 PG 30 2.5 3 5 336 None 23 NED None
3 61/M T1N0M0 PG 1 SND 65 333 334 None 16 NED None
4 53/M T1N0M0 PG 1 SND 65 2.5 3 4 335 None 14 NED None
5 55/M T1N0M0 PG 30 335 335 None 17 NED None
6 82/M T1N1M0 PG 1 SND 95 436 437 RT 14 AWD Trismus
7 55/M T1N1M0 PG 1 SND 65 333 334 RT 12 NED None
8 46/M T1N1M0 PG 1 SND 65 334 435 RT 13 AWD None
9 35/M T1N1M0 PG 1 SND 70 333 435 RT 12 NED None
10 61/M T1N1M0 PG 1 SND 65 334 435 RT 14 NED None
11 43/M T1N1M0 PG 1 SND 70 333 434 RT 12 AWD None
Abbreviations: AWD, alive with disease; NED, no evidence of disease; PG, partial glossectomy; RT, radiation therapy; SND, selective neck dissection.

Figure 2. The shape and size of the flap depended on the shape of Figure 3. The harvested flap was sutured to the tongue and pri-
the tongue, which had been resected (arrow: parotid duct). mary closure was performed at the donor site (arrow: neurovascu-
lar pedicle).

in an anterior to posterior direction. The flap was elevated

in the loose areolar plane between the buccinator muscle
and the buccopharyngeal fascia. The neurovascular pedicle
was identified. Dissection continued inferiorly and laterally
and lower and posterior incisions were made, and then the
flap was elevated (Figure 3).
The neurovascular pedicle was dissected from the sur-
rounding tissues. Ordinarily, the buccal artery and vein were
included in this flap, thus requiring more careful dissection.
The harvested flap was sutured to the tongue, and primary
closure of the donor site was carried out. Two or 3 weeks
after the surgery, the pedicle was clipped and carefully
examined by Doppler. After that, we divided the pedicle
with ultrasonic scissors (harmonic scalpel) under local
anesthesia. Twelve months after surgery, only a linear scar
remained at the donor site, and the tongue motion was good
(Figure 4).
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Results
All flaps were harvested and transposed successfully. The
buccal artery and vein composed a vascular pedicle and sup-
plied the buccinator flap. In these patients, there were no
local tumor recurrences and no problems with mastication,
oral competence, or facial nerve function. Eight patients
experienced concurrent neck dissection (Table 1).
All patients were followed up for at least 12 months (mean,
18 months), and oral functions were assessed. Eleven patients
returned to nearly preoperative stages of mouth opening.
However, 1 patient had a partial limitation in mouth opening
(Table 2). In speech and swallowing, all patients returned to
nearly normal levels within 1 month after pedicle division.
There were no differences between speech and swallowing
preoperatively and speech and swallowing 12 months later.
The mobility of the reconstructed tongue was also compared
Woo et al 229

elimination of the need for an external incision, reduced donor

Figure 4. Twelve months after surgery, the linear scar was excised
at the donor site and the viability of the buccinator myomucosal
flap was good.
with the normal side. When the tongue mobility on the normal
side was assumed as 100%, the flap side mobility was approxi-
mately 80%. In addition, the flap volume at 12 months post-
operatively was found to have decreased to 10% to 40% of the
volume at 1 month postoperatively (Table 2). However, the
tongue was covered by oral mucosa; thus, the contracture was
not advanced.
Discussion
The use of intraoral local flaps harvested from the internal
cheek area has been introduced in recent literature.20-22 The
advantages of such flaps include the amount of tissue avail-
able, the ability to replace mucosa with mucosa, the
site morbidity, and optimal functional and cosmetic results.23
For these reasons, moderately sized defects represent a major
reconstructive challenge, the main goals of which are to restore
the internal oral lining, preserve or improve the function of
residual structures, replace the mucosa with tissues having sim-
ilar features, and obtain the best aesthetic result possible. The
use of local myomucosal flaps harvested from the cheek area
is one of the best means of achieving these objectives.22
The buccinator myomucosal flap, one of the intraoral local
flaps introduced by Zhao et al17 in 1999, represents a useful,
versatile technique for correcting defects in any part of the
oral cavity with good results and minimal morbidity. This flap
is similar to lingual tissue, consisting of thin, pliable mucosa
capable of mucus production, with a high cell renewal rate
and minimal scar formation, as well as excellent color, con-
tour, texture match, and buccinator muscle fibers over the
flap’s entire length, providing tongue muscle reconstruction
without a conspicuous donor site. In the past, these flaps were
used primarily for reconstruction of cleft palate defects.21
In this study, we use the buccinator myomucosal flap
based on the buccal artery and vein. The buccinator myomu-
cosal flap could be applied for tongue defects due to tongue
cancer that require a neck dissection; however, Zhao et al16
did not recommend the buccinator myomucosal flap when
the facial artery and vein were invaded by cancer. The bucci-
nator myomucosal flap supplied by the buccal artery is then
suitable for N0 to N1 neck disease24 because it would not be
affected by the upper neck node dissection where commonly
the facial artery and vein are sacrificed to eradicate the meta-
static nodes in the submandibular area. In our series, concur-
rent neck dissection was performed in 8 patients, including
level Ib dissection. The flap was not compromised because
its blood supply came from the buccal artery.
The buccinator myomucosal flap is known to be optimal
in edentulous patients20,24,25 because the absence of tooth

Table 2. Result of oral functions.

Mouth Opening, cm Tongue Mobility, % Flap Volume,a cm3 Speech, % Swallowing, Points

Patient Postoperative Normal Flap Postoperative Postoperative Postoperative Postoperative

No. Preoperative 12 mo Tongue Tongue 1 mo 12 mo Preoperative 12 mo Preoperative 12 mo

1 4.5 4.3 100 90 4.32 3.88 100 100 10 9

2 5.2 5.3 100 80 6.28 5.02 100 100 10 9
3 4.0 3.9 100 80 4.19 2.51 100 100 10 10
4 4.2 4.0 100 80 5.23 3.92 100 100 10 9
5 4.9 5.2 100 80 5.01 4.26 100 100 10 10
6 4.4 2.9 100 70 7.33 4.76 100 90 10 10
7 3.4 3.0 100 80 4.09 3.76 100 95 10 9
8 3.7 3.5 100 90 4.37 3.22 100 100 10 10
9 4.1 3.7 100 80 5.43 4.30 100 95 10 10
10 3.5 3.2 100 80 5.44 3.90 100 100 10 10
11 3.6 3.5 100 90 4.76 4.13 100 100 10 9
a
Flap volume = p/6 3 length 3 width 3 height.

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230
elements eliminates the need for postoperative forced mouth
opening that is usually used to avoid flap pedicle injuries
during mastication, without patient discomfort. In our series,
we employed this flap in partially edentulous patients to
avoid the possibility of the patient biting the pedicle; how-
ever, we believe that this flap can also be used in dentate
patients if the patient is in good compliance not to bite the
pedicle until the pedicle is divided. In fact, we have experi-
ence using this flap in a dentate patient, and he recovered
without any complications (data not shown).
Regarding the buccinator myomucosal flap’s donor site,
its very low morbidity has been one of its main advan-
tages,16,18,22,26 due to the possibility of closure with a direct
suture or through advancement of the buccal fat pad. Of the
patients in this study, 1 of 11 patients experienced trismus,
and this patient was 1 of 6 who received adjuvant radiation
therapy. This allows for optimal functional and cosmetic
recovery, confirming the major role played by this flap in
the reconstruction of moderate-size defects following
tongue resections.27 The aesthetic results were excellent in
all patients, without external scars or cheek depressions.
If the distance between the superior and inferior margin
of the flap is more than 4 cm, skin grafting may be needed.
If more tissue is needed, the parotid duct can be replanted.
Finally, to improve tongue mobility and mouth opening, the
flap pedicle is usually sectioned between 2 and 4 weeks
after surgery under local anesthesia.
Conclusion
The use of the buccinator myomucosal flap is a very good
option for reconstructing moderately sized (one-third to
one-half) oral cavity defects, because of its versatility, the
short operating time required for the procedure, the possibil-
ity of using tissue with mucosa, and low donor site morbid-
ity. Accompanying node dissection of level Ib is not a
contraindication to this flap because this flap receives a
blood supply from the buccal artery.
Author Contributions
Seung Hoon Woo, contributions to conception and design, acquisi-
tion of data, or analysis and interpretation of data; Han-Sin Jeong,
contributions to conception and design, acquisition of data, or anal-
ysis and interpretation of data; Jin Pyeong Kim, data acquisition,
manuscript draft; Jung Je Park, data acquisition, manuscript draft;
Junsun Ryu, study concept, manuscript draft; Chung-Hwan
Baek, study concept, manuscript draft.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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