Invest Clin 62(4): 307 - 315, 2021 https://doi.org/10.22209/IC.v62n4a02

Corresponding author: Hawree Abdulsattar Hasan. Sulaimaniya Burn and Plastic Surgery Hospital, Sulaimaniyah,

Kurdistan Region-Iraq. Email: Hawre978@yahoo.com

Role of the facial artery musculomucosal

flap in the reconstruction of palatal defects.

Hawree Abdulsattar Hasan1, Ari Raheem Qader2, Ala Esmail Shakur1,

Ari Hasan Rashid1 and Shakhawan Saeb Zorab1

1 Sulaimaniya Burn and Plastic Surgery Hospital, Sulaimaniyah, Kurdistan Region. Iraq.

2 Collage of Medicine, University of Slemani, Sulaimaniyah, Kurdistan Region. Iraq.

Key words: cleft palate; FAMM flap; inferiorly based; oral cavity; palatal fistula;

superiorly based.

Abstract. The facial artery musculomucosal flap (FAMM flap) is a conve-

nient option for covering complicated palatal defects, as it is a local flap inside

the oral cavity with good tissue quality and minimal drawbacks. The present

prospective study included 17 patients, 7 males and 10 females. Most of the

patients had palatal fistulae, after cleft palate surgical repair; only one had a

post-traumatic palatal defect. Superiorly based FAMM flaps were used for eight

patients, and inferiorly based FAMM flaps were used for nine patients. A speech

specialist assessed all patients, postoperatively. The range of follow-up time was

from two to four years. In the majority of cases, reconstruction was successful

and uneventful. Patients were satisfied regarding oral function. Complications

were minor, which include incomplete coverage, bulkiness, temporary hardness

and dimpling. The FAMM flap is a very useful, versatile, and technically easy flap

for covering difficult palatal defects.

308 Hasan et al.

Investigación Clínica 62(4): 2021

Papel del colgajo músculo-mucoso de la arteria facial

en la reconstrucción de defectos palatinos.

Invest Clin 2021; 62 (4): 307-315

Palabras clave: fisura de paladar; colgajo FAMM; base inferior (flujo anterógrado);

cavidad oral; fistula de paladar; base superior (flujo retrógrado).

Resumen. El colgajo músculo-mucoso de la arteria facial (FAMM) es una

opción conveniente para cubrir los defectos palatinos complicados, como un

colgajo local dentro de la cavidad oral, con buena calidad de tejido y míni-

mos inconvenientes. Diecisiete pacientes, 7 masculinos y 10 femeninos, fue-

ron incluidos en nuestro estudio prospectivo. La mayoría de los pacientes

tenían una fístula de paladar después de la reparación quirúrgica de fisura de

paladar; solo uno tenía un defecto palatino postraumático. Se utilizaron los

colgajos FAMM de base superior en 8 pacientes, y los colgajos FAMM de base

inferior se utilizaron en 9 pacientes. Todos los pacientes fueron evaluados

en el postoperatorio por un especialista en habla. El intervalo de tiempo de

seguimiento fue de 2 a 4 años. En la mayoría de los casos, la reconstrucción

fue exitosa y sin incidentes. Los pacientes quedaron satisfechos con respecto

a la función oral. Las complicaciones fueron menores, e incluyeron cobertura

incompleta, aumento de volumen, dureza temporal y hoyuelos. El colgajo

FAMM es un colgajo muy útil, versátil y técnicamente fácil para cubrir los

defectos palatinos difíciles.

Received: 04-04-2021 Accepted: 31-05-2021

INTRODUCTION

The FAMM flap is an axial flap composed

of mucosa and submucosa from the intraoral

cheek, part of the buccinator muscle and the

deepest part of the labial orbicular muscles

including the facial artery (1, 2). Pribaz et al.

discussed the FAMM flaps, which consist of

the mucosa, submucosa, a small amount of

buccinators muscle, the deeper plane of the

orbicularis oris muscle and the facial artery

and venous plexus (3).

The buccinator muscle is a wide, flat,

quadrangular muscle; its medial surface is

covered by submucosa and mucosa. Its con-

sidered part of the sphincteric muscle com-

plex used for sucking, whistling, propelling

food, and voiding the oral cavity. This mus-

cle’s blood supply is from the buccal artery

and small branches from the alveolar artery

(4). The facial artery, a branch of the exter-

nal carotid artery, hooks around the mandi-

ble body immediately anterior to the masse-

ter muscle. It courses deep into the risorius,

zygomaticus major, and superficial lamina of

the orbicularis oris muscle. It lies superficial

to buccinators, the levator anguli oris, and

the deep lamina of the orbicularis muscle.

The facial artery is located approximately

1.5 cm (range 9.2 to 19.8 mm) lateral to the

oral commissure, giving rise to the superior

and inferior labial arteries (5).

The FAMM flap can be designed accord-

ing to its need as either superiorly based

Facial artery musculomucosal flap covering palatal defects 309

Vol. 62(4): 307 - 315, 2021

(antegrade) or inferiorly based (retrograde)

flap, and both types have been proved to be

reliable (1,6). The superiorly based FAMM

flap can be used to cover the defects in

the hard palate, alveolus, nasal lining, up-

per lip and sometimes even the orbit. The

inferiorly based FAMM flap can be used for

defects in the alveolus, floor of the mouth,

lower lip and vermillion and tonsillar fossa

(7). FAMM flap can also be used in case of

post-ablation maxillofacial defects, an infe-

riorly based FAMM flap can be used only for

the facial artery. If possible, the linguofacial

vein has been preserved in neck dissections.

If the vein has been ligated, venous drainage

can still be ensured by preserving wide soft

tissue at the base (8).

Advantages over other regional flaps in-

clude its axial blood supply permitting the

extended length, minimal donor-site mor-

bidity, and flexibility to have either a supe-

rior or inferior pedicle. Drawbacks of FAMM

include its difficulty of tunneling for palatal

reconstruction in patients with intact denti-

tion. These kinds of patients have to use a

bite block to avoid chewing on the pedicle,

and another operation is required for flap di-

vision (9). Other complications, like any oth-

er flaps, are partial or complete necrosis of

the flap, buccal branch of facial nerve injury

that might lead to oral corner asymmetry,

particularly during difficult dissection (1).

To minimize complications, careful dissec-

tion should be done so that the facial artery

goes along the flap’s whole length. The flap

remains axial; also, care should be taken to

prevent twists or constraints on the pedicle.

With careful attention to these details, the

FAMM flap remains reliable, versatile, and

extremely useful (3).

The palatal defect can result mainly af-

ter excision of the tumor, cleft palate, oro-

nasal fistulas, and alveolar, the floor of the

mouth, and vermilion loss. Nasolabial flaps

have been performed to reconstruct midfa-

cial defects, and buccal flaps have been used

to reconstruct midfacial defects (10, 11).

Pribaz et al. (3) have designed by combining

the principles of nasolabial and buccal mu-

cosal flaps, FAMM flap.

This study’s objective was to review

functional results and complications that oc-

curred in our cases with palatal defects that

the FAMM flap have been used for them as

a primarily or previously operated on cases.

MATERIALS AND METHODS

This prospective study included 17 cas-

es with a palatal defect that attended the Su-

laimaniya Burn and Plastic Surgery Hospital,

Sulaimaniya city, Iraq. The patient’s age was

between 2 to 40 years, 7 of them were fe-

male, and 10 patients were male. Nine flaps

were based inferiorly, and eight flaps were

based superiorly. The most common cause

of the palatal defect was palatal fistula after

cleft palate surgical repair (15 cases); other

causes of the palatal defect were primary

wide palatal defect (one case), and bullet in-

jury (one case) (Table I). Sixteen cases were

secondary cases previously treated with oth-

er conventional modalities that failed, like

turndown flap, tongue flap, buccal flap, and

one of them has been previously, unsuccess-

fully treated with a FAMM flap.

A list of patient characteristics, indica-

tions and type of procedure is shown in Table I.

The FAMM flap can be designed supe-

riorly or inferiorly based. All patients were

under general anesthesia with endotracheal

intubation. A mouth gag was inserted. Mark-

ing was outlined first outside using handheld

Doppler ultrasound; the flap centered over

the facial artery and one cm away from the

month’s angle, as shown in Fig. 1.

With the help of a small gauge needle,

we determined the flap’s edges from inside

and marking it after marking the Stenson’s

duct. Then we did double-checking from in-

side through using a handheld Doppler ul-

trasound, as shown in Fig. 2.

The flap’s orientation became oblique,

and the width of the flap is ranged between

1.5 to 2 cm and was well anterior to the

Stenson’s duct. This is illustrated in Fig. 3.

310 Hasan et al.

Investigación Clínica 62(4): 2021

TABLE I

PATIENT CHARACTERISTICS & TYPE OF PROCEDURE

No. Age & Sex History & Diagnosis Type of FAMM flap

1 12y, ♂Anterior palatal defect due to fistula. Inferiorly based FAMM flap.

2 8y, ♂Anterior palatal defect due to fistula. Inferiorly based FAMM flap.

3 9y, ♂Anterior palatal defect due to fistula. Superiorly based FAMM flap.

4 9y, ♂Anterior palatal defect due to fistula. Superiorly based FAMM flap.

5 10y, ♀Anterior palatal defect due to fistula. Inferiorly based FAMM flap.

6 8y, ♀Anterior &mid palatal defect due to fistula. Inferiorly based FAMM flap

7 8y, ♀Anterior &mid palatal defect due to fistula. Inferiorly based FAMM flap.

88y, ♂ Anterior &mid palatal defect due to fistula. Superiorly based FAMM flap.

9 2y, ♂Anterior &mid palatal defect due to fistula,

with the history of buccal flap failure.

Right side.

Inferiorly based FAMM flap.

10 4y, ♂Anterior palatal defect due to fistula. Superiorly based FAMM flap.

11 18y, ♀Mid palatal defect due to fistula. Inferiorly based FAMM flap.

12 16y, ♀Unrepaired wide bilateral cleft palate. Inferiorly based FAMM flap used

for aiding cleft palate repair.

13 18y, ♂Bilateral alveolar cleft. Superiorly based FAMM flap &

cancellous bone graft.

14 40y, ♂Bullet injury causing big palatal fistula. Superiorly based FAMM flap &

cancellous bone graft.

15 35y, ♂Oronasal fistula, with a history of tongue

flap failure.

Superiorly based FAMM flap.

16 16y, ♀Anterior palatal defect due to fistula. Inferiorly based FAMM flap,

failed due to necrosis.

17 4y, ♀Anterior &mid palatal defect due to fistula,

which we did for her previously right

inferiorly based flap, and it failed

Left Superiorly based FAMM

flap.

Fig. 1. Marking of the FAMM flap from outside.

Facial artery musculomucosal flap covering palatal defects 311

Vol. 62(4): 307 - 315, 2021

After infiltration of lidocaine with

adrenaline and waiting for 7 minutes, we did

an incision using Colorado-tipped electro-

cautery through mucosa, then submucosa.

After incision of the buccinators mus-

cle we searched for the facial artery as it is

demonstrated in Fig. 4.

The dissection is carried out from distal

to proximal according to the base of the flap,

which is either superior or inferior as shown

in Fig. 5.

After identifying the facial artery, liga-

tion and cutting of the artery was done, the

rest of the flap was incised, and dissection

was done just deep to the facial vessels with

taking a small amount of the buccinators

muscle and deep plane of the orbicularis oris

muscle.

The facial artery was included along the

whole axis of the flap, which is critical for

making the flap axial and well perfused, and

the length of the flap was between 8 to 13

cm with length to width ratio 5:1, as stated

in Fig. 6.

Then we did two layers of closure, which

was possible in all 17 cases, by approximat-

ing the buccinators flap. We put a bite block

in some cases of the superiorly based flap.

RESULTS

All cases were subjectively assessed in

the postoperative period to determine the

anatomical separation of the nasal cavity

from the oral cavity and improve the patient’s

speech by a speech therapist. The results

showed a good satisfactory improvement

which was noticed in all of our cases. In the

majority of cases, reconstruction was suc-

cessful and uneventful. The flap’s bulkiness

was also noticed especially in the early weeks

after surgery, without causing any problem

during speech and eating. This problem was

Fig. 2. Double-checking with the aid of a handheld

Doppler.

Fig. 3. Marking of the flap from inside.

Fig 4. Dissection of the flap.

312 Hasan et al.

Investigación Clínica 62(4): 2021

gradually decreased in size with time. In one

case, we were not able to close the defect

completely by just using the FAMM flap due

to the size of the defect, so there was a good

improvement in the patient’s speech with

the help of speech therapy but still, the pa-

tient have fistula and nasal regurgitation.

Flap viability

In one of our cases (5%), a 4-year-old

female with a mid and anterior palatal de-

fect, due to fistula post cleft palatal repair;

a right side inferiorly based flap was used,

the flap developed complete necrosis. The

reason behind this was not explained, we did

Fig. 5. a) Superiorly and b) inferiorly based FAMM flap

Fig.6. a) length and b) width of the flap.

Facial artery musculomucosal flap covering palatal defects 313

Vol. 62(4): 307 - 315, 2021

debridement and redo the surgery with the

use of contralateral superiorly based FAMM

flap with the good flap survival and viability.

Another case (5%) developed partial necro-

sis of the flap, we also did debridement of

the necrotic tissue but fortunately, it did

not affect the coverage of the defect and the

overall result of the surgery.

Donor side

In all of our cases, primary closure was

possible at the donor side. In the beginning,

there were some kinds of tightness, espe-

cially during mouth opening, but this effect

became better after time.

One case developed dimpling in the

lower part of his check at the donor side.

No muscle weakness during facial anima-

tion has been observed in all 17 cases as the

facial nerve branches were preserved. Figs.

7- 9 are demonstrated in some of our cases.

Patient satisfaction

Patients were satisfied regarding oral

function. Complications were minor, which

include incomplete coverage, bulkiness,

hardness at the donor site, dimpling, facial

asymmetry and partial necrosis.

Fig. 7. 10 years old female. (inferiorly based FAMM flap done to close an anterior palatal fistula).

Fig. 8. Bilateral alveolar clefts (Superiorly based FAMM flap was done).

314 Hasan et al.

Investigación Clínica 62(4): 2021

DISCUSSION

Palatal defects are difficult problems be-

cause they functionally affect the patients by

nasal regurgitation and speech problems, apart

from the anatomical defects. It most commonly

occur as a complication of cleft palatal repair,

resulting in a wide and scarred fistula. One of

the most reasonable solutions for that is the

use of a FAMM flap, composed of mucosa and

submucosa with a part of the buccinators and

orbicularis oris muscles along with the facial

artery and vein. It can be designed according

to the position and state of the defect either

inferiorly or superiorly based (3). Being a kind

of axial flap means the facial artery is included

along the whole length of the flap which helps

covering of a defect with the size of 3-8 cm

without the risk of flap viability; in this way, it

can be used for covering small to medium size

palatal defects (1). The other benefit of the flap

is the lack of risk of nerve injury as the facial ar-

tery is far deeper than the facial nerve branch-

es, that is why the facial artery can be included

safely in the flap through the whole length of

the flap. There is also the advantage of replac-

ing like with like as it uses oral mucosa for cov-

ering the mucosal defect. There is no external

scar by using the FAMM flap as with nasolabial

flap, so there will be a good aesthetic result.

Furthermore, it can be used along with the tu-

mor excision and reconstruction in the same

operative field at the same operation time.

Our study shows the use of a FAMM flap

for reconstruction of a palate defect. Due to

the rich blood supply of the region, the flap

could be raised safely. In all of our cases, pri-

mary closure was possible at the donor side.

The flap is robust and thick, therefore gives

enough bulk to the palate and allows the de-

fect to be closed. Due to the leakage, using

a prosthesis to closure of soft palatal defects

mostly creates a poor functional outcome.

Closure of large palatal defects have been

usually accomplished with palatal prosthetic

devices (12).

Other studies investigated the use of

FAMM flap for reconstruction of palate de-

fects. Doldere et al. (12) investigated the

use of an extended FAMM flap with the ap-

propriate mucosal muscle skin tissue for

reconstruction of a soft palate defect. They

concluded that this flap allows not only the

treatment of the palatal defect, but also

management of dribbling secondary to a

marginal mandibular palsy.

Sumarroca et al. (1) investigated the

reconstruction of oral cavity defects with

Fig. 9. A 40 years old man with palatal fistula and bone defect following a bullet injury. unilateral superiorly

based FAMM flap done.

Facial artery musculomucosal flap covering palatal defects 315

Vol. 62(4): 307 - 315, 2021

FAMM flaps. In that study, reconstruction

was successful in 92% of cases. Oral func-

tion and ingestion were satisfactory in all

patients. Therefore, they concluded that the

FAMM flap is useful and reliable for recon-

struction of some small to medium-sized

intraoral defects. The functional reconstruc-

tion of the oral cavity can be achieved with

a low risk of complications (1). Xie et al.

(13) studied modified FAMM flaps for recon-

struction of posterior skull base defects. Us-

ing the fascia of the masseter muscle, they

have developed a new modified FAMM flap.

In addition, they concluded that the retro-

grade FAMM flap should only be applied as

an alternative when other clinically proven

options are not appropriate. Fang et al. (14)

investigated various buccinator musculomu-

cosal flaps for palatal fistulae closure after

cleft palate surgery. They concluded that the

flap is a suitable option for fistula repair. It

is good for greater fistulae at the junction of

hard and soft palate or at the anterior por-

tion of the hard palate (14).

As a review of our cases, we believe that

the FAMM flap is a very reliable and versa-

tile flap used for palatal defect with a techni-

cally easy procedure with many advantages

and minimal post-operative complications.

We recommend its use for difficult small to

medium sized palatal defects as a result of

cleft palatal surgery complications or even

any other causes of palatal defects.

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