Buccal Myomucosal Flap Research Articles

An innovative appliance to prevent trauma to the pedicle of buccal myomucosal flap

ABSTRACT Buccal myomucosal flap or buccal flap is an established procedure for the treatment of velopharyngeal dysfunction. This flap is harvested from cheek based posteriorly in retromolar region and transferred to the soft palate region for lengthening of the palate. This is used for nasal lining and/or for closure of oral mucosa defect. There is a risk of crushing of pedicle of the flap in adolescents and adults when molars are erupted. An innovative orthodontic appliance has been designed to be placed over mandibular anteriors to create an open bite in the region of molars. This appliance has been used in 2 clinical cases successfully preventing trauma to the pedicle of the flap. This appliance is fabricated in the dental laboratory after taking mandibular and maxillary impressions. This appliance is fitted over the mandibular anterior teeth and patient can remove and put back. The patient can be trained about the use of the appliance peroperatively. It is easy to fabricate, user-friendly, and inexpensive. There was no complication in terms of temporomandibular joint pain or teeth movement.

Does Primary Cleft Palate Repair by Furlow Z-Plasty Technique With a Buccinator Myomucosal Flap Change Speech and Middle Ear Outcomes?

Children with repaired cleft lip and palate may present with middle ear effusion and disturbed speech due to velopharyngeal (VP) insufficiency. Furlow Z-palatoplasty with a buccinator myomucosal flap is one of the effective surgical techniques for primary cleft palate repair and lengthening of the palate. This study aimed to evaluate the effect of Furlow Z-palatoplasty with buccal myomucosal flap as a primary cleft palate repair technique on the VP function during speech and the Eustachian tube function. Forty patients with non-syndromic cleft lip and palate aged 3 to 7 years surgically repaired with Furlow palatoplasty with a buccinator myomucosal flap were assessed. Perceptual speech assessment, nasopharyngoscopic examination, otoscopic examination, and tympanometry were done for all patients to assess the speech and middle ear function. The percentage of mild hypernasality was significant in 22.5% of children with repaired cleft lip and palate, while 77.5% showed no hypernasality. Speech intelligibility was normal in 77.5% and mildly affected in 22.5% of children with repaired cleft palate. Compensatory misarticulations were recorded in 12.5% of children. Nasopharyngoscopic examination revealed adequate VP closure in 75% of children with repaired cleft palate. Twenty-five percent of children with repaired cleft lip and palate had middle ear effusion and required myringotomy with insertion of tympanostomy tubes. Primary cleft palate repair with Furlow Z-palatoplasty with buccal myomucosal flap had beneficial effects on speech outcomes. It was associated with a low prevalence of middle ear effusion, and a low number of tympanostomy tubes were needed.

Effectiveness of secondary furlow palatoplasty with buccal myomucosal flap in correction of velopharyngeal insufficiency in patients with cleft palate

ObjectivesThe main purpose of this study was evaluation of the effectiveness of secondary furlow palatoplasty with buccal myomucosal flap (FPBF) for the treatment of velopharyngeal insufficiency (VPI) in patients with a cleft palate who were treated with two flap palatoplasty (TFP) in their primary palate repair.Material and methodsTwenty-three medically free children aged 4–8 years with non-syndromic and previously repaired cleft palate via TFP participated in the study. All patients received secondary surgery following the technique of FPBF. Preoperative speech evaluation was done before the secondary repair and 3 months after the surgery using a hypernasal speech scale, speech intelligibility scale, and nasopharyngoscopy.ResultsA statistically significant improvement was observed regarding the degree of hypernasality and speech intelligibility while comparing the preoperative scores after the primary surgery to the postoperative scores after the secondary surgery.In addition, a statistically significant improvement was found in the nasopharyngoscopic assessment.ConclusionsThe incorporation of a buccal myomucosal flap with Furlow palatoplasty was successful in improving hypernasality, speech intelligibility, and nasopharyngoscopic scores in patients with cleft palate.Trial registrationclinicaltrials.gov (NCT05626933).Clinical relevanceThis technique might be the surgical technique of choice while treating patients who are suffering from VPI after cleft palate repair.

Pleomorphic Adenoma of the Soft Palate: The Pillars of Reconstruction

Salivary gland tumour contributed less than 5% of all head and neck tumours. The most common benign tumour of the salivary glands is pleomorphic adenoma. Palate is the common subsite in the oral cavity affected by this tumour. We herein discussed a case of pleomorphic adenoma of the soft palate and the reconstruction dilemma. A 41-year-old male presented with soft palate swelling, which gradually increasing in size in the last 5 years. Intraoral examination revealed well defined, 3x3 cm circumscribed mass at the soft palate, not crossing the midline, encroaching the hard palate, but spared the retromolar trigone and gingivobuccal sulcus. Incisional biopsy performed and histopathological examination showed features of pleomorphic adenoma. He underwent wide local excision of the pleomorphic adenoma with reconstruction using buccal myomucosal flap. Buccal flap was an excellent choice due to its proximity with good recovery. Pleomorphic adenoma of minor salivary gland of the soft palate was managed by complete excision but reconstructing the palatal defect was the cornerstone of managing this tumour. The aim was to preserve functionality and to prevent velopharyngeal insufficiency. Buccal myomucosal flap offered both advantageous, in addition to its proximity to the defect with negligible donor morbidity.

Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-Analysis.

Buccal myomucosal flaps (BMF) anatomically lengthen the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing literature on speech outcome of BMF palatal lengthening. Three databases were used to identify studies of interest published in English. Studies that did not use standardized speech assessments were excluded. PRISMA checklist was followed, and the risk of bias in the included studies was assessed. Long-term follow up of patients. With history of cleft palate presenting with VPI. BMF palatal lengthening. Random-effects model meta-analyses were performed for hypernasality, intelligibility, and nasal air emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment. From the initial 7115 articles, 13 were included in this review. Two of these had a significant patient overlap and a study with a smaller patient population was excluded. All 12 included articles met the National Institutes of Health Quality Assessment Tool criteria. Six retrospective studies evaluated 230 patients and six prospective studies evaluated 181 patients. The most common indications for BMF were large size of the velopharyngeal gap and prior surgery for VPI. Meta-analyses demonstrated effect sizes below zero, confirming the improvement of standardized assessment scores in patients with VPI after BMF palatal lengthening. Egger regressions revealed low risk of publication bias. BMF palatal lengthening provides adequate treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.

Comparative Effectiveness of Secondary Furlow and Buccal Myomucosal Flap Lengthening to Treat Velopharyngeal Insufficiency.

Secondary Furlow (Furlow) and buccal myomucosal flaps (BMMF) treat velopharyngeal insufficiency by lengthening the palate and retropositioning the levator veli palatini muscles. The criteria for choosing one operation over the other remain unclear. A single-center retrospective cohort study was conducted. Thirty-two patients with nonsyndromic, repaired cleft palate were included. All patients underwent a Furlow or BMMF. Outcome measures included (1) resolution of hypernasality 12 months postoperatively, (2) degree of improvement of hypernasality severity; and (3) change in velar length, as measured on magnetic resonance imaging scans obtained preoperatively and 12 months postoperatively. All measures were performed by raters blinded to participants' medical and surgical history. Hypernasality was corrected to normal in 80% of the Furlow group and in 56% of the BMMF group. Patients receiving BMMF had more severe hypernasality during preoperative speech evaluation. Both groups had a median decrease of two scalar rating points for severity of hypernasality (P = 0.58). On postoperative magnetic resonance imaging, patients who underwent Furlow had a median increased velar length of 6.9 mm. Patients who received BMMF had a median increased velar length of 7.5 mm. There was no statistically significant difference between groups regarding increase in velar length (P = 0.95). Furlow and BMMF procedures increase velar length with favorable speech outcomes. The same degree of improvement for hypernasality was observed across groups, likely explained by the similar increase in velar length achieved. Anatomic changes in palate length and levator veli palatini retropositioning persist 1 year after surgery.

Effects of two flap palatoplasty versus furlow palatoplasty with buccal myomucosal flap on maxillary arch dimensions in patients with cleft palate at the primary dentition stage: a cohort study

ObjectiveThe objective of this study was to evaluate the effect of two flap palatoplasty (TFP) versus Furlow palatoplasty with buccal myomucosal flap (FPBF) on maxillary arch dimensions in children at the primary dentition stage with cleft palate, in comparison to matching subjects without any craniofacial anomalies.Material and methodsThis study included 28 subjects with an age range of 5–6 years; 10 non-cleft subjects were included in the control group, 9 patients treated with TFP, and 9 patients treated with FPBF. For the included patients, the maxillary models were scanned using a desktop scanner to produce virtual models, and the maxillary dimension measurements were virtually completed. The produced measurements were compared between the 3 groups. Maxillary models of the 28 participants were evaluated.ResultsStatistically insignificant differences were detected between the 3 groups for arch symmetry measurements. Differences were detected in the inter-canine width between the 2 surgical groups and non-cleft group. Both arch length and posterior palatal depth significantly differ while comparing the TFP to the control group, with no differences between FPBF and the non-cleft group.ConclusionFurlow palatoplasty with buccal myomucosal flap might be considered a better surgical option than two flap palatoplasty for patients with cleft palate while evaluating maxillary arch dimensions at the primary dentition stage as a surgical outcome.Clinical relevanceThis study gives insight into the surgical technique that has limited effect on the maxillary growth and dental arch dimension. Therefore, it decreases the need for orthodontic treatment and orthognathic surgery.Trial registrationclinicaltrials.gov (NCT05405738).

128. Propeller Buccal Myomucosal Flap: Anatomical Study and Preliminary Experience in 25 Primary Cleft Palate Reconstructions

128. Propeller Buccal Myomucosal Flap: Anatomical Study and Preliminary Experience in 25 Primary Cleft Palate Reconstructions

D119. Propeller Buccal Myomucosal Flap: Anatomical Study and Preliminary Experience in 25 Primary Cleft Palate Reconstructions

PURPOSE: Buccal artery myomucosal (BAMM) flap has been well-described for cleft palate reconstruction. However, anatomic analysis and application of a completely islanded propeller flap have not been reported in the literature. METHODS: Anatomical study was performed using Indocyanine green, red and blue latex injected directly into the buccal pedicle of 22 fresh hemifacial cadavers. Then, clinical analysis of the senior authors’ (BBG, AR) experience with 25 consecutive primary cleft palate reconstructions utilizing a propeller islanded BAMM flap was conducted to assess palatal healing and flap outcomes. RESULTS: Mean buccal artery diameter was 0.95±0.29mm. Neurovascular pedicle entered the flap 11.38±2.87mm anterior to the pterygomandibular raphe. Buccal artery advanced inside the flap as much as 66.8%±6.0% of the total flap length. All reconstructions were performed using Furlow palatoplasty. 36 flaps were utilized in 25 patients (mean age 478d). The mean maximum cleft width was 11.7 mm. Mean BAMM flap width was 1.2 cm and 11 cases utilized bilateral flaps. The flap always reached the contralateral pillar and the buccal nerve was always preserved. Mean follow-up was 400 days. There were 2/36 flap loss. In both flap losses, pedicles were aggressively dissected. 4/36 flaps underwent revision for flap debulking. CONCLUSION: This study shows that the buccal pedicle is the main blood supply to the flap and this modification allows preservation of the sensory innervation. The contralateral pillar could always be reached improving the traditional advancement and inset. Traditional extensive propeller flap dissection should be avoided in these neonates to avoid vascular compromise.

Treatment of Velopharyngeal Insufficiency Using Bilateral Myomucosal Buccinator Flaps.

The buccinator myomucosal flap, also referred to as a buccal myomucosal flap, is an effective technique to address velopharyngeal insufficiency after cleft palate repair. Challenges related to flap harvesting may deter plastic surgeons from incorporating this strategy as a first-line treatment. The primary objective of this study and accompanying video is to provide support regarding indications, planning, and surgical steps of the buccinator myomucosal flap technique, including important technical details for soft-palate dissection and flap harvesting.

"Buccal Myomucosal Flap Repair for Velopharyngeal Dysfunction."

Velopharyngeal dysfunction is the incomplete separation of the nasal and oral cavities during speech sound production that can persist following primary palatoplasty. Surgical technique used in management of velopharyngeal dysfunction (palatal re-repair versus pharyngeal flap or sphincter pharyngoplasty) is often dictated by the preoperative velar closing ratio and closure pattern. Recently, buccal flaps have increased in popularity in management of velopharyngeal dysfunction. Here, we investigate the effectiveness of buccal myomucosal flaps in the treatment of velopharyngeal dysfunction. A retrospective review was performed of all patients undergoing secondary palatoplasty with buccal flaps at a single center between 2016-2021. Pre- and postoperative speech outcomes were compared. Speech assessments included perceptual examinations, graded on a four-point scale of hypernasality, and speech videofluoroscopy, from which velar closing ratio was obtained. A total of 25 patients underwent buccal myomucosal flap procedures for velopharyngeal dysfunction at a median of 7.1 years after primary palatoplasty. Patients had significantly increased velar closing postoperatively (95% vs 50%, p<0.001) and improved speech scores (p<0.001). Three patients (12%) had continued hypernasality postoperatively. There were no occurrences of obstructive sleep apnea. :' Treatment of velopharyngeal dysfunction with buccal myomucosal flaps leads to improved speech outcomes without the risk of obstructive sleep apnea. Traditionally, palatal re-repair techniques have been utilized for smaller preoperative velopharyngeal gaps; however, the addition of buccal flaps allows for anatomic velar muscle correction for patients with a larger preoperative velopharyngeal gap.

Speech Outcomes Following Operative Management of Velopharyngeal Dysfunction (VPD) in Non-Syndromic Post-Palatoplasty Cleft Palate Patients.

Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients. An academic tertiary pediatric care center. Retrospective cohort study. Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL). The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS). 97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant (P < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P < .05). Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP.

Buccal Myomucosal Flap for Reconstruction of Red Lip Defects Close to Mouth Angle.

Owing to the special esthetic and functional role in the face, red lip reconstruction presents a challenge to plastic surgeons. Various reconstructive techniques can be employed to fix the red lip defects close to the mouth angle. The purpose of this study was to demonstrate that the buccal myomucosal flap could be an available option to repair red lip defects with preservation of its esthetics and function. A single-center, retrospective study of 7 patients with red lip defects who were treated with buccal myomucosal flap was conducted between June 2017 and March 2022. All patients were followed up for at least 6 months including questionnaires and photography. Of these 7 patients, 2 were women, and 5 were men. The average age was 14.3 years (range, 1-32y). All the buccal myomucosal flaps survived well. All the donor sites were closed directly without complications. The average follow-up time was 33.4 months (range, 6-57mo). All patients were satisfied with the aesthetic and functional results. The buccal myomucosal flap is versatile and reliable, with the advantages of rich vascularity, flexible design, and easy access. This study was presented to highlight that the flap could be a good candidate to treat red lip defects close to the mouth angle.

Pleomorphic Adenoma of the Palate: A Rare Case in an Adolescent With Cleft lip and Palate.

Benign salivary gland tumors are rarely found in children and adolescents compared with adults. Pleomorphic adenomas (PAs), the most common benign salivary gland tumor, account for only 1% of all head and neck lesions and fewer than 5% of all salivary gland tumors in individuals under the age of 16 years. The data on palatal PA in the first 2 decades of life is confined to published case reports and case series. To date, there has never been a report of palatal PA in a patient with cleft lip and palate. Here we describe an adolescent female with bilateral cleft lip and palate with PA of the hard and soft palate who underwent wide local excision and reconstruction with a buccal fat pad and buccal myo-mucosal flap.

An Algorithmic Approach for Deploying Buccal Fat Pad Flaps and Buccal Myomucosal Flaps Strategically in Primary and Secondary Palatoplasty.

Recent publications have introduced the use of buccal myomucosal and fat pad flaps to augment palatal repairs with autologous tissue. We propose a workflow for intraoperative decision-making to introduce these adjuncts into standard palatoplasty procedures. A retrospective chart review of a single-surgeon series of patients undergoing primary and secondary palatoplasties performed between October 2017 and November 2020 was completed after Institutional Review Board approval. Patient demographics, phenotype, operative details, and postoperative complications were recorded. Fifty-eight patients were included in a review. For those undergoing primary repair, 23.3% underwent a Furlow palatoplasty alone, 46.3% had a Furlow palatoplasty accompanied with acellular dermal matrix (ADM) and/or a buccal fat flap (BFF). A unilateral buccal myomucosal flap (BMMF) with or without augmentation with BFF or ADM was employed in 16.3% of the cases. Fourteen percent required a bilateral BMMF+/- ADM. Fistula occurrence was 2.3% (n = 1). For revisions, 27% underwent only a conversion Furlow palatoplasty, 26% had a conversion Furlow palatoplasty accompanied with ADM and/or a BFF, 33% had a unilateral BMMF or BMMF/ADM, and 14% required a bilateral BMMF+/- ADM. In severe phenotypes or complicated cases, buccal fat flaps and myomucosal flaps may be utilized. This approach has mostly replaced the use of ADM over time. An algorithmic approach to palatoplasty allows surgeons to tailor the extent of surgery to the needs of each patient.

Modified Buccal Myomucosal Flap Closure of Large Anterior Palatal Oronasal Fistulas.

Large oronasal palatal fistulas can be challenging to reconstruct. The authors present a modified buccal myomucosal flap repair technique and review intermediate-term outcomes. In this technique, large anterior palatal fistulas are closed in two layers. First, apposing nasal turnover flaps of vomer mucosa medially and nasal wall mucosa laterally are approximated. Second, a posteriorly based buccal flap incorporating full-thickness buccinator muscle and overlying mucosa is transposed with interposition of the flap in the retromolar trigone and lateral palate to preserve dental occlusion. Consecutive patient cases performed in low-resource settings were reviewed and outcomes reported. Among eight subjects aged 3 to 22 years, with average defect size of 2.5 cm2 (range, 0.8 to 3.5 cm2), the flap was viable in all cases and required revision or pedicle division in only two patients (25 percent); all patients showed symptom improvement. The modified buccal myomucosal flap shows promising intermediate-term results as a single-stage reconstruction suitable to a wide patient age range, low airway/anesthetic risk, reliable functional outcomes, and low comorbidity.

Reconstruction of a Gunshot-Caused Mouth Floor Defect Using a Nasolabial Flap and a De-Epithelialized V-Y Advancement Flap

We present reconstruction of a gunshot-caused mouth floor defect using a nasolabial flap and a de-epithelialized V-Y advancement flap.A 58-year-old man presented 14 days after bullet injury passed from anterior chin to the right postauricular area. Upon examination, the central incisors, alveolar bones, and soft tissues of the mouth floor were lost. Bone fragments and failed miniplates were exposed. Pus discharge filled the defect.On the 23rd post-trauma day, right unilateral nasolabial flap was used to cover the oral side of the mouth floor. This flap was centered on the nasolabial fold and its base was situated on the commissure of the lips. The flap was raised in the soft tissue, just superficial to the facial muscles, transferred into the oral cavity through an incision made in the cheek mucosa, and sutured to the margin of the defect. A de-epithelialized dermal and subcutaneous flap was used to reconstruct the deep portion of the mouth floor through the V-Y advancement method. At the lower border of the mandible, a 3-cm-wide V-Y advancement flap was designed. The de-epithelized portion was inserted into the mouth floor and sutured to the defect margin. On 30th post-trauma day, left commissure-based buccal mucosal flap was used for the gingivobuccal sulcus defect. The apex was near the retromolar trigone. The elevated flap was transferred to the lower gingivobuccal sulcus defect. On POD 28, the nasolabial flap and commissure-based buccal myomucosal flap was divided and inset respectively.These flaps can be used for moderate-sized mouth floor defects.

The Effectiveness of the Buccal Myomucosal Flap on Speech and Surgical Outcomes in Cleft Palate: A Systematic Review

Purpose: A systematic review was conducted to assess speech and velopharyngeal competence outcomes following the buccal myomucosal flap surgical approach used for primary palatoplasty and secondary surgery for velopharyngeal insufficiency (VPI) in individuals with cleft palate. Methods: A systematic review was guided by the PRISMA guidelines. Articles were included if the patients received the surgical technique for primary cleft palate repair or secondary surgery for VPI and if the study provided detailed methods on the perceptual speech assessment or visualization of postoperative velopharyngeal anatomy. Results: A total of 1013 patients were included from 11 studies. Post-surgery, normal resonance was achieved in 77.4% of patients and no nasal air emission was reported in 54.7% of patients. An improvement in velopharyngeal closure was reported in 81.8% of patients. A variety of perceptual speech assessment scales and methods for assessing velopharyngeal competence were used in the studies. Conclusions: The review suggests that the buccal myomucosal flap procedure results in improved velopharyngeal closure as evidenced by physiologic observation and reported perceptual changes in speech intelligibility, resonance balance, and reduced nasal air emission. The development of an international, standardized method for assessing and reporting speech outcomes and velopharyngeal competency is recommended to ensure accurate comparisons between surgical techniques. Keywords: Buccal flap, systematic review, perceptual speech assessment, speech outcomes, surgical outcomes. Read more →

An Intraoperative Salvage After Transection of the Greater Palatine Artery During Cleft Palate Repair: A Case for Buccal Fat and Buccal Myomucosal Flaps

Recently, several adjunctive procedures have gained traction to aid cleft surgeons in repairing especially challenging palatal clefts. Buccal fat flaps and buccal myomucosal flaps have demonstrated particular utility in reinforcing thin palatal flaps or tissue deficits. Although their use has not been widely accepted, they may be particularly helpful in the setting of significant scarring or vascular compromise. Here the authors describe the case of an intraoperative salvage using bilateral buccal fat flaps and a right buccal myomucosal flap after transection of the right Greater Palatine artery (GPA) during palatoplasty on a 14-month old female with Pierre Robin Sequence and a wide Veau II cleft palate. For this operative salvage, bilateral buccal fat flaps were used to reinforce the hard-soft palate junction and a 4 cm × 2 cm flap of the right-sided buccal mucosa and buccinator muscle was inset along the majority of the right-sided soft and posterior hard palate. At 2 years follow-up, the patient had no significant complications and was doing well with healthy-appearing palatal tissue and age-appropriate speech.

The Buccal Myomucosal Flap For Reconstruction In Oral Cavity Cancers

The Buccal Myomucosal Flap For Reconstruction In Oral Cavity Cancers