The facial artery musculomucosal flap: Modification of the harvesting technique for a single-stage procedure

The facial artery musculomucosal (FAMM) flap was first described in 1992 by Pribaz et al.1 This flap allows reconstruction of small- to medium-size oral cavity, oropharynx, and intranasal defects.2-4 Lateral and anterior floor-of-mouth (FOM) defects have been successfully reconstructed with the FAMM flap, maintaining the tongue mobility and ensuring adequate elocution and the oral phase of deglutition. The FAMM flap can also be used for reconstructions of other subsites of the oral cavity as well as the lip and vermillion reconstruction.5 However, a second-stage procedure is often needed to reduce the bulky mucosal paddle at the base of the flap, to increase the depth of the vestibule and to allow greater mobility of the mobile tongue. A second-stage procedure is required in approximately one third of the patients.3 We present herein a modification of the surgical approach of the FAMM flap to allow a one-stage procedure and the surgical outcomes in three cases. The facial artery, a collateral branch of the external carotid artery, exits the submandibular region of the neck and ascends over the inferior border of the mandible through the antegonial notch. The facial artery follows an ascending and tortuous route toward the medial angle of the eye. On its path, it passes laterally to the buccinator (deepest layer) and medially to the risorius, zygomaticus major, and superficial lamina of the orbicularis oris. The flap includes mucosa, submucosa, part of the buccinator, and an underlying facial artery and submucosal venous plexus. The flap is designed over the facial artery trajectory with an oblique orientation, from the retromolar trigone to the level of the ipsilateral labial sulcus. The venous drainage relies on a submucosal plexus. Therefore, identification and preservation of the facial vein is not mandatory during dissection. However, the base of the flap needs to be wide enough (approximately 2 cm) to ensure a good venous drainage. The FAMM flap, used in FOM reconstruction, is based inferiorly (antegrade flow) for all patients. The length of the flap is tailored proportionally to the size of the defect. The Stensen's duct limits the width of the flap posteriorly, which is kept under 3 cm to avoid tension of closure of donor site. Anteriorly, the incision lies 1 cm posterior to the oral commissure. A Doppler ultrasound may be used to mark the course of the facial artery, but this is rarely needed.5 The dissection starts with the localization of the facial artery. It can be done either through an incision in the most distal part of the flap to directly locate the facial artery, or through an incision in the labial commissure area to identify the superior labial artery, and that could be traced back to the facial artery. The initial incision is done through the mucosa, submucosa, and buccinator. The flap is then elevated and should include the facial artery, the overlying buccinator, and a small portion of the orbicularis oris close to the oral commissure. The facial artery is kept attached to the overlying tissues in the entire length of the flap (Fig. 1). Anterior and lateral floor-of-mouth defect shown in light grey. Classical facial artery musculomucosal flap design in the inner cheek in dark grey. A = facial artery trajectory; B = superior labial artery. The proximal margin is located at the alveolar crest. The flap is then rotated with the pedicle bridging over the alveolar crest (Fig. 2). If teeth are present, extractions of the second and first molar —up to the first bicuspids—are usually indicated allowing a better adaptation of the flap. The facial artery musculomucosal flap is rotated to fill the floor-of-mouth defect. The base of the flap bridges over the alveolar crest. The rough edges of the flap will not be sutured over the alveolar crest and will create a bridge of soft tissue over the intact alveolar crest mucosa. Bridging of the pedicle over the alveolar crest is avoided by using the base of the pedicle to fill the posterior part of the FOM defect instead of keeping it attached to the cheek. This is achieved by extending the anterior incision over the alveolar crest to reach the FOM defect (Fig. 3). The base of the flap is then dissected in the deep plane over the alveolar crest either submucosally or subperiosteally. In the latter case, the mandibular periosteum needs to be incised along the alveolar crest (Fig. 4). Design of the modified facial artery musculomucosal (FAMM) flap. The anterior edge of the FAMM flap is prolonged over the alveolar crest to reach the floor-of-mouth defect. The depth of the gingival incision reaches the periosteum, which is lifted under the base of the pedicle. If required, the floor-of-mouth defect can be lengthened posteriorly to facilitate inset of the anterior edge of the facial artery musculomucosal flap without mucosal redundancy. Thus, after elevation, the flap is rotated and inserted into the FOM defect. With this modification the base of the flap is used to fill the posterior part of the FOM defect and cover the alveolar crest at the same time. Also, the anterior part of the flap is sutured on its whole length to the medial part of the FOM defect and is no longer partially floating over the alveolar crest. Suturing of the distal and posterior part of the flap is done as usual to the anterior and lateral parts of the defect (Fig. 5). The facial artery musculomucosal flap has been rotated to fill the floor-of-mouth defect. The base of the flap rotates over the alveolar crest. The rough edges of the flap are sutured on their whole length. The posterior edge of the base of the flap is sutured to the buccal mucosa and previously cut gingival mucosa. The anterior edge of the base of the flap is sutured to the most medial edge part of the defect. We used the modified FAMM technique in three patients for FOM reconstructions (Fig. 6-9). The patients included two males and one female, with ages ranging from 47 to 89 years. All three patients had been diagnosed with a squamous cell carcinoma of the FOM, which were clinically staged as either T1 or T2. Perioperative view after the resection of a floor-of-mouth squamous cell carcinoma. Design of the modified facial artery musculomucosal flap. The striped area represents the modification of the flap. The base of the flap is then dissected in the deep plane over the alveolar crest either submucosally or subperiosteally. Appearance of the facial artery musculomucosal flap 1 month postoperatively. Following the primary resection, a functional neck dissection was performed and the facial artery was preserved in all patients. The FAMM flap was used to cover the anterior and lateral FOM defect. Partial glossectomy was performed in two patients, and the tongue was closed primarily. One patient received postoperative radiation therapy. No patient required a second-stage procedure. All three patients resumed normal diet. No dental rehabilitation was needed as all three patients had enough remaining teeth. Speech quality was considered satisfying by all patients and their families. They could be understood by strangers on the phone. The FAMM flap is presently our preferred method of reconstruction for small to medium-sized FOM defects. It provides an elastic cushion for prosthetic apparatus, remains malleable, and does not shrink postoperatively.6 Also, its reliability, ease of harvest, proximity to the defect and similar mucosal lining, absence of external scar, and low rate of significant complications are invaluable advantages. The need to perform a second-stage procedure represents a potential drawback, which can be avoided by the modification described herein.

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