SciELO - Scientific Electronic Library Online

 
vol.27 número4Colgajo miomucoso de buccinador en la reconstrucción de defectos del área maxilofacialSchwannoma parafaríngeo gigante: Diagnóstico diferencial y enfoque terapéutico índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

Servicios Personalizados

Revista

Articulo

Indicadores

Links relacionados

  • En proceso de indezaciónCitado por Google
  • No hay articulos similaresSimilares en SciELO
  • En proceso de indezaciónSimilares en Google

Compartir


Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.27 no.4 Barcelona jul./ago. 2005

 

Artículo Clínico


Reconstruction of palatal defects with the buccinator muscle flap

Reconstrucción de defectos palatinos con el colgajo de músculo buccinador

 

M. Cuesta Gil1, R. Pujol Romanyà2, C. Navarro Cuellar2, B. Duarte Ruiz2, H. Nieto2, T. Bucci2, C. Navarro Vila3


Abstract: Defects of the palate that are of a significant size require reconstruction with local or distant flaps in order to avoid important functional sequelae such as oronasal regurgitation and rhinolalia.
The buccinator muscle flap, described by Bozola in 1989 for closing palatal fistulas and for reconstruction of the soft and hard palate, represents an important therapeutic alternative for this type of defect.
In this work we present an anatomic-clinical description and the surgical technique with the myomucosal flap of buccinator muscle, as well as a small series of patients operated on in the Gregorio Marañon Hospital from the year 2000 to the year 2004. Of a total of 12 patients with palatal defects that were reconstructed using this flap, 4 were men and 8 were women. The defects in 5 cases were located in the hard palate and 7 were located in the soft palate. Primary reconstruction was carried out following oncological resectioning in 10 cases, while in 1 case secondary reconstruction was carried out after failure with a temporalis muscle flap, and in another patient it was used to cover a preprosthetic bone graft. The aesthetic and functional results were excellent in 10 out of 12 cases. The most common complication was dehiscence of the suture which occurred in five cases, three of which were resolved spontaneously and in another two cases it was necessary to re-operate.
The buccinator muscle strikes us an interesting reconstruction technique for defects of the palate. It represents a surgical method that is simple and hardly aggressive, with very few sequelae and good results. It can also be used for resolving defects of the lip, tongue, jugal mucosa and of the orbits, as well as for cases of velopalatal insufficiency.

Key words: Buccinator myomucosal flap; Palate; Reconstruction.

Resumen: Los defectos palatinos de un tamaño significativo precisan reconstrucciones con colgajos locales o a distancia para evitar secuelas funcionales importantes, como regurgitación oronasal y rinolalia.
El colgajo de músculo buccinador, descrito por Bozola en 1989 para el cierre de fístulas palatinas y reconstrucciones del paladar blando y duro, supone una interesante alternativa terapéutica en este tipo de defectos.
En este trabajo presentamos una descripción anatómico-clínica y de la técnica quirúrgica del colgajo miomucoso de buccinador, así como nuestra pequeña casuística de pacientes operados en el Hospital Gregorio Marañón desde el año 2000 al 2004. De un total de 12 pacientes con defectos palatinos que fueron reconstruidos utilizando este colgajo, 4 eran hombres y 8 mujeres. La localización del defecto fue en 5 casos en el paladar duro y en 7 en paladar blando. Se realizaron reconstrucciones primarias tras resecciones oncológicas en 10 casos, mientras que 1 caso ha sido una reconstrucción secundaria tras fracaso de un colgajo temporal y, en otro paciente se utilizó para cubrir un injerto óseo preprotésico.
Los resultados estéticos y funcionales fueron excelentes en 10 de los 12 casos. La complicación más frecuente fue la dehiscencia de sutura que se presentó en 5 casos, 3 de los cuáles fueron dehiscencias parciales que se resolvieron espontáneamente y, en los otros 2 casos, se precisó una reintervención.
El colgajo de músculo buccinador parece una interesante técnica reconstructiva para defectos palatinos. Constituye un método quirúrgico sencillo, poco agresivo, con mínimas secuelas y buenos resultados. También puede ser empleado para resolver defectos de labio, lengua, mucosa yugal y órbitas, así como en casos de insuficiencia velopalatina.

Palabras clave: Colgajo miomucoso buccinador; Paladar; Reconstrucción.

Recibido: 1 de abril de 2005

Aceptado: 22 de julio de 2005


1 Médico adjunto.
2 Médico residente.
3 Jefe de Servicio de Cirugía Oral y Maxilofacial. Catedrático de Cirugía Oral y Maxilofacial
Universidad Complutense de Madrid.
Hospital General Universitario Gregorio Marañón, Madrid, España

Correspondencia:

Dr. Matías Cuesta Gil
C/ Ibiza 66 1º D - 28009 Madrid, España

 

Introduction

The reconstruction of the palate nearly always entails a technical challenge for the surgeon as it is an area that is difficult to access and, on many occasions, small defects require complex and delicate techniques in order to be repaired efficiently. For this reason, in the recent past and including today, there are schools that do not repair defects of the palate claiming that if there is local relapse there is better control.

The first buccinator muscle flap was described by Kaplan,1 in 1975, who used an oral mucosal flap for covering the floor of the nasal fossa of the soft palate. Later Maeda et al. (1987)2 added fibers of buccinator muscle for repairing patients with cleft palates. Finally, Bozola3, in 1989, was the first to design a myomucosal flap of buccinator muscle based on the buccal artery as the principle pedicle. He used it for closing palatal fissures and for reconstruction of defects of the palate. In 1991, Carstens et al.4 described a flap based on the artery and facial veins for closing oral defects. Zhenmin, 2 in 1999, carried out an extensive anatomical study of this flap, observing two vascularization patterns of the buccinator muscle and as a result, two different flaps, one based on a posterior pedicle (buccal artery and posterior buccal branch of the facial artery) and the other based on a superior pedicle (distal portion of the facial artery through the anterior buccal branches).

The myomucosal flap of buccinator muscle is a variation of a useful technique for reconstructing significantly large defects in the orofacial area where direct closure cannot be carried out or where the use of more complex flaps is not justified. This could lead to serious aesthetic and functional sequelae in the donor area leading to an increase in surgical risk.

In this work we present the experience over the last four years in the Service of Oral and Maxillofacial Surgery of the Hospital Gregorio Marañon of Madrid. Our series is of 12 patients with defects in the palatal bone or soft palate, or in both, that were reconstructed with a buccinator myomucosal flap with a posterior pedicle, either on its own or combined with other flaps (Bichat’s fat pad and/or a palatal flap).

Material and methods

Surgical anatomy
The anatomy of the buccinator muscle is very constant. The buccinator muscle originates behind the pterygomandibular raphe, as well as from portions of the alveolar process of the upper and lower maxilla. Anteriorly, it blends with the orbicularis oris muscle. Laterally it covers the masseter muscle, the mandibular branch, Bichat’s fat pad and the buccopharyngeal fascia. Medially, it is covered by buccal mucosa and submucosa. There is a plane where it can be dissected easily between the muscle and fascia5-8.

Arterial supply
The buccinator muscle receives arterial flow through three main sources. The buccal artery (internal maxillary branch of the artery) represents the most important pedicle. The posterior, inferior and anterior buccal branches of the facial artery (external carotid artery) represent the second source of vascular supply. The terminal branches of the infraorbital artery and of the posterosuperior alveolar artery (branches of the internal maxillary artery), are of lesser importance.

The buccal artery, which is the principal source of supply of the buccinator muscle, goes underneath the pterygoid muscle reaching the posterior half of the buccinator muscle. The facial artery has many branches: between one and three branches emerge in order to supply the lower half of the muscle. Posteriorly, the facial artery continues its tortuous route in an anterior-superior direction by the oral commissure to then give off another three of five small branches that irrigate the anterior half of the buccinator muscle.

The third pedicle comes from the posterosuperior alveolar artery that has numerous temporal branches, and which enter through the upper margin of the buccinator muscle or through its posterior half.

This multiple irrigation allows great versatility on harvesting the flap.

Venous drainage
Numerous veins originate in the lateral surface area of the buccinator muscle. After converging, the buccal venous plexus is formed in the posterior portion of the muscle. Later, this plexus drains into the facial vein through a variable number of tributary veins entering the pterygoid plexus that flows behind, and above, and superficially to the buccinator muscle. The more anterior portion drains directly into the facial vein through various tributary veins.

Motor innervation
This takes place around the temporal and cervical division of the facial nerve that occurs near Bichat’s fat pad, forming a dense network (buccal branches). Numerous outflowing branches reach the deeper side of Bichat’s fat pad in order to be distributed within the buccinator muscle. This multiple distribution permits us as surgeons to raise part of the muscle without any denervation of the remaining portion.

Sensitive innervation
This takes place along the long buccal nerve. It emerges from the lateral pterygoid muscle and goes in an inferior and anterior direction, and in a superficial and parallel direction to the buccal artery, reaching the buccinator muscle in its upper, posterior portion.

A very important anatomic feature of the buccinator muscle is the parotid duct, that reaches the level of the second molar, slightly above its central portion.

Surgical technique

Harvesting a buccinator muscle flap should start with the identification of the bud of the parotid gland or Stenon’s duct. In order to avoid harming this and the facial nerve, the flap has to be raised 0.5 cm underneath the bud. It should be harvested on the same side of the defect that is to be repaired and the incision should include the mucosal plane and the complete thickness of the muscle to the outer fat plane allowing a great arc of rotation. During the dissection, all the arterial and venous branches of the flap that is to be harvested should be identified and preserved, and for this using a color Doppler can be useful. Mucosal application of Lidocaine with Epinephrine 1:100.000 can be useful in order to facilitate dissection and local hemostasis.

Depending on the defect to be covered, the flap can be raised with different rotation bases, each supplied by one of the three arterial pedicles previously described.

• Posterior base: supplied by the buccal artery.
• Inferior base: supplied by the facial artery.
• Anterior base: supplied by the angular artery

Despite the large capacity of this flap to be rotated, excessive rotation should be avoided as this can lead to vascular compression with the resulting damage and loss, especially when it is freed while depending on the buccal artery. When the flap is freed and the long buccal nerve is conserved, trophism of the muscle is maintained and in this way a greater muscular mass is achieved that in those cases where the muscle is denerved.5

If the distance between the upper and lower margins is not above 2.5 cm, primary suturing can be carried out on the defect in the donor area. When the width is greater, the donor area should be repaired.

Cases report

Between october 2000 and june 2004, twelve patients were operated on by the Service of Oral and Maxillofacial Surgery in the Hospital General Universitario Gregorio Marañón, as they had palatal defects that were repaired using a buccinator muscle flap with a posterior pedicle. The average age of the patients was 62, with ages ranging between 31 and 88 years. The sex distribution was 8 women (66.6%) and 4 men (34.7%). The preoperative diagnosis was 6 patients with adenoid cystic carcinoma, 1 ameloblastoma, 1 monomorphic adenoma, 1 pleomorphic adenoma, 2 palatal fistulae and 1 case of exposure of an iliac crest graft in preprosthetic surgery (Table 1). The defects of the palate to be repaired were located in the following anatomical areas: 5 in the hard palate, 3 in the soft palate, 1 between the hard and soft palate and in 3 cases the upper maxilla was affected in the posterior portion. The average size of the defect was 3.8 cm2, varying between 2 and 7.5 cm2. In all cases the operation was carried out using general anesthesia. In the oncological patients a wide resection was carried out with safety margins and immediate reconstruction. In 4 patients a Bichat’s fat pad flap was joined, and in another a palatal flap, and in one patient the size of the defect that had been created required joining a buccinator muscle flap, a Bichat’s fat pad and an ipsilateral palatal flap (Case 2). The donor area was sutured directly in 9 cases and a dermoepidermic graft was placed in the remaining three.

At the end of the surgery all patients were given enteral nutrition through a gastric tube for a minimum of 7 days.

Case report 1
This was a 58-year-old female patient who had been operated on a year previously for an adenoid cystic carcinoma at the back of the palate on the left side. During the postoperative period she had suffered a Klebsiella infection as a result of an allergy to the suture normally used, that led to the loss of a myofascial flap of temporalis muscle. The patient had sequelae of intense trismus with an aperture of at least 1 cm, and oro-sinusal communication. During the intervention a coronoidectomy was carried out and the masticatory muscle was freed of the fibers. Normal oral aperture was achieved intraoperatively. The oro-sinusal communication was corrected adequately by means of a myomucosal flap of buccinator muscle with a posterior pedicle (figs. 1 y 2).

Case report 2
A 79 year old patient had come to our Service as a result of a bulge at the back of the palate on the left side. The CT examination showed a tumorlike mass that measured 3 x 2 cm that was located on the midpalate on the left side that was very close to the tuberosity but with no apparent infiltration. The biopsy report was: adenoid cystic carcinoma. A posterior maxillectomy was carried out on the left side together with a palatectomy that included the second molar and all the tuberosity of the maxilla. The extensive defect left was reconstructed by joining a buccinator flap, a palatal flap and a Bichat’s fat pad flap (figs. 3 y 4).

Results

Of the 12 patients in our series, the final results obtained were excellent in 9 patients aesthetically as well as functionally, as there was no loss or infection of the flaps. In one case, the global result was bad and in another it was average, due to the speech disorders created. We had one case of exitus due to acute cardiorespiratory arrest on the 5th postoperative day. The patient was 88 years old and she had a serious cardiac pathology. She had been diagnosed with a adenoid cystic carcinoma of the soft palate. Four patients had partial dehiscence of the suture line. In two the problem was resolved spontaneously, and nutrition was maintained through the nasogastric tube for a further 10 to 15 days. In another 2 cases, a second intervention was needed for readapting the flaps, with rhinolalia being the sequela in one patients. None of the patients had sequelae in the donor areas.

Discussion

Palatal defects of a significant size represent a challenge for the surgeon due to the large aesthetic and functional sequelae that these cause when not reconstructed adequately.

Historically, various surgical techniques have been used for palatal reconstruction. Spontaneous granulization was one of the solutions most applied in the past. But this is only effective in minimal defects that do not require resecting the palatal bone. This technique requires more time for healing and for wound closure with the inconvenience that this has for the patient, as daily treatment will be required, the use of a nasogastric tube for enteral nutrition during an extended period, with the final result being poor from the anatomic and functional point of view. There will also be sequelae such as rhinolalia, velopalatal incompetence and difficulty on swallowing. The use of an obturator prosthesis can improve these defects and the patient can carry out basic functions, but this always entails added discomfort as a result of the size of the prosthesis, mucosal irritation and difficult hygienic care. This technique has been displaced by the development of new procedures, and it is only used for a very select number of patients with very small defects, or for patients with high morbidity and for whom surgery on a large scale is not indicated. When the defects originated by the resection are of a moderate or large size, and if patient conditions allow it, reconstruction will be carried out by using local or distant flaps.9-15

The rich vascularization of the oral cavity permits designing various types of local flaps. There are different possibilities for trying to restore the anatomic-functional integrity of the defect, according to where the defect is located. The inconvenience of these types of defects is the limited tissue volume that they have and the lack of adaptability, which limits their use to areas that are adjacent and very small. In larger sized defects, the use of a regional pedicled flap is needed. Those that are most used are the temporoparietal fascia flap and the temporalis muscle flap16. These flaps are easy to adapt and they have a sufficient amount of volume to cover defects of a moderate or large size. They have the inconvenience of being restricted by a pedicle, which reduces the possibilities in real terms. A considerable aesthetic defect is also caused in the donor region that requires implanting alloplastic material for its correction, increasing morbidity. Other regional flaps that have been used are: naso-genian, platysma muscle, and the sternocleidomastoid muscle.17

The development of microsurgical techniques has allowed carrying out post-oncological reconstruction of a greater size while solving the defects in a very anatomical way with aesthetic and functional results that are very acceptable.18 The high surgical time and morbidity in the donor area produced by the harvesting of distant flaps with microsurgery, means that this type of surgery is ruled out for patients with an underlying pathology, elderly patients and those in the high anesthetic risk group.

The buccinator muscle flap represents an alternative for palatal defects of a moderate size, where closure by means of suturing directly or simple local flaps is not possible, and for those where the use of regional or distant flaps cannot be justified.

Although initially it was described for the repair of small or moderately sized defects of the palate, the indications for the myomucosal buccinator flap are becoming more and more extensive as a result of the many types of vascular pedicles and forms of harvesting it, and it can be used for the reconstruction of half the upper or lower lip, defects of the midface, periorbit and for partial glossectomies.19 It is extremely useful for the reconstruction and sealing of perioral defects, as the mucosa is intact and there is sufficient amount of tissue for covering palatal and maxillary defects that are either homolateral or contralateral. Its great pliability allows adapting and repairing complex anatomical regions of the oral cavity where other conventional techniques have failed. The buccinator muscle flap represents a simple technique that is fast and relatively unaggressive. It is a very reliable flap as it has rich vascularization, and a considerable amount of muscle and mucosal tissue is supplied for repairing defects of a significant size. The possibility of transferring a flap with innervation permits reconstruction that is more physiological especially when repairing the tongue. It offers the possibility of reconstructing the different areas of the orofacial region such as: the orbit, palate, lips, floor of the mouth and tongue,20,21 while leaving minimal or no sequelae in the donor area. Generally, the donor area can be closed directly or with a local advancement flap. Only in the cases of defects that are more than 2.5 cm wide is the use of a dermo-epidermic graft advised in order to avoid scar retraction.

In defects of a large size, the association of a Bichat’s fat pad flap and/or a palatal flap increases the reparative possibilities.

The buccinator muscle flap represents an easy and reliable technique, but it is not exempt of complications. The most common complication is suture dehiscence and the subsequent release of the flap, especially when it is used for the reconstruction of the hard and soft palate.10-13 In order to avoid this, it is important to fix the pedicle to the oral mucosa along its entire length, so as not to avoid it being pulled down by its weight, contributing to its dehiscence.

Another complication that is not so common but that is no less important, is damage to the parotid duct. In order to avoid this, it is important to identify and design the flap that is 0.5 cm underneath it.

Excessive rotation of the flap, especially when the flap is based on the buccal artery, can lead to the damage of the flap and later loss. This is an unusual complication due to the rich vascularization of this flap.

Other complications have been described such as: difficulty with oral aperture or damage to some of the branches of the facial nerve (damage to the marginal branch, especially if the dissection of the flap is started through the lower margin).

The only disadvantage we can point out is that the quantity of tissue it offers is limited.22

References

1. Kaplan EN. Soft palate repair by levator muscle reconstruction and a bucal mucosal flap. Plast Reconstr Surg 1975;56:129.        [ Links ]

2. Maeda K, Ojimi H, Utsugi R, Ando SA. T-shaped musculomucosal flap method for cleft palate surgery. Plast Reconstr Surg 1987;79:888.        [ Links ]

3. Bozola AR, Gasques JA, Carriquiry, y cols. The buccinator myomucosal flap: Anatomic study and clinical application. Plast Reconstr Surg 1991;88:33.        [ Links ]

4. Carstens MH, Stofman Gt, Sotereanos GC. The buccinator myomucosal island pedicle flap: Anatomic study and case report. Plast Reconstr Surg 1991;88:39.        [ Links ]

5. Zhenmin Z, Senaki L, Yiping Y, y cols. New buccinator myomucosal flap: Anatomic study and clinical application. Plast Recontr Surg 1999;104:55-64.        [ Links ]

6. Shipkov C, Simoiv R, Bukov Y, y cols. The nasolabial flap and the buccinator flap. Anatomic study and 2 cases reports. Annales de chirutgie plastique esthétique 2003;48:152-8.        [ Links ]

7. Sobotta. Atlas de Anatomía Humana. Putz y R. Pabst. Eds. Editorial Panamericana, 2001.        [ Links ]

8. Lloyd DuBrul E. Anatomía Oral. Doyma, 1988.        [ Links ]

9. Anastassov GE, Schwartz E, Rodríguez E. Buccinator myomucosal island flap for postablative maxillofacial reconstructions: a report of 4 cases. J Oral Maxillofac Surg 2002;60:816-21.        [ Links ]

10. Hill C, Riaz M, Leonard AG. A technique for repair of the «unrepairable» cleft palate. Br J Plast Surg 1999;52:658-71.        [ Links ]

11. Caubet Biayna J, Iriarte Ortabe J, Lasa Menéndez V, Puedo J. Buccinator flap for closure of large palatal defects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:507-8.        [ Links ]

12. Caubet Biayna J, Iriarte Ortabe JI, Pueyo J. Reconstruction of a palatal defect with pedicled myomucosa flap of buccinator muscle. Ann Otorrinolarigol Ibero Am 1998; 25:263-70.        [ Links ]

13. Licameli GR, Dolan R. Buccinator musculomucosal flap: applications in intraoral reconstruction. Arch Otolaryngol Head Neck Surg 1998;124:69-72.        [ Links ]

14. Kuran I, Sadikoglu B, Turan T, Hacikerim S, Bas L. The sandwich technique for closure of a palatal fistula. Ann Plast Surg 2000;45:434-7.        [ Links ]

15. Reychler H. Technics of velopalatal reconstructions. Ann Chir Plast Esthet 1989; 34:129-35.        [ Links ]

16. Tung-Yiu Wong, DDS, Ching-Hung Chung, DDS, Jehn-Shyun Huang, DDS, MS, PhD and Hung-An Chen, DDS. The inverted Temporalis Muscle Flap for Iintraoral Reconstruction: Its Rationale And The Results of Its Application. J Oral Maxillofac Surg 2004;62:667-75.        [ Links ]

17. Yi-Fang Zhao, Wen-Fen Zhang, Ji-Hong Zhao. Reconstruction of intraoral defects after cancer surgery using cervical pedicle flaps. J Oral Maxillofac Surg 2001;59:1142-6.        [ Links ]

18. Nehrer-Tairych GV, Millesi W, Schuhfried O, Rath. A comparision of the donorsite morbidity after using the prelaminated fasciomucosal flap and the fascicutaneous radial forearm flap for intraoral reconstruction. Br J Plast Surg 2002;55:198- 202.        [ Links ]

19. Zhao Z, Zhang Z, Li Y, Li S, y cols. The buccinator musculomucosal island flap for partial tongue reconstruction. J Am Coll Surg 2003;196:753-60.        [ Links ]

20. Ono, Ichiro, Gunji, Hironori, y cols. Reconstruction of defects of the entire vermilion with a bucal musculomucosal flap following resection of malignant tumors of the lower lip. Plast Renostr Surg 1997;100:422-30.

22. Stofman GM, Carstens MH, Berman PD, Arena S, Sotereanos GC. Reconstructions of the floor of the mouth by means of an anteriorly based buccinator myomucosal island flap. Laryngoscope 1995;105: 90-6.        [ Links ]

23. Guan-fu Chen, DDS, MD, Lai-ping Zhong, DDS. A Bilateral musculomucosal buccal flap method for cleft palate surgery. J Oral Masillofac Surg 2003;61:1399- 404.        [ Links ]

Creative Commons License Todo el contenido de esta revista, excepto dónde está identificado, está bajo una Licencia Creative Commons