INTRODUCTION
In 1989, the author described1 his
experience with the use of the musculo-mucosal buccinator2 flap to correct palatine fistulas and fissures with soft
palate elongation when the fissured slopes are short or in cases of fissure
correction that resulted in primary treatment of the short palate with its
phonological consequences. It also covers areas of bloody post-resection site
of
tumors within its rotation arc and treatment of mandibular osteomyelitis1.
The anatomy is described again according to the initial studies and the technique
for obtaining the flap. Six cases of palatine fissures treated with palatoplasty
with a follow-up period of 27 years were found in the original publication
series and were included in this study.
OBJECTIVE
This study aimed to review the statements and observations mentioned initially
(1989) regarding the use of the musculo-mucosal buccinator flap. In addition,
it
compared a case treated with the classic techniques that also had a 27-year
postoperative follow-up and had a similar treatment solution and evolution.
METHODS
The results after 27 years of follow-up of 6 patients treated with a mucosal
buccinator for cleft palate correction at Base Hospital and Santa Casa de São
José do Rio Preto from 1984 to 1989 were analyzed and reassessed in 2016. The
present study follows the ethical principles of the Declaration of Helsinki and
obtained signed Informed Surgical Consent forms from the patients included in
the study.
Anatomy
The buccinator muscle is located deep in the cheek and has a slightly
quadrangular shape (Figure 1A). Its
inner surface is covered by the oral mucosa. The other surface is in contact
with the masseter muscle, mandible branch, medial pterygoid muscle,
buccopharyngeal fascia, and adipose body of the cheek (Bichat’s adipose
ball). Between it and the oropharyngeal fascia is a loose areolar plane that
facilitates dissection-divulsion and obtaining of the flap.
Figure 1 - A and
B: Shape, origin, and
insertion of the buccinator muscle occupying the lateral region
of the mouth
3,4.
Figure 1 - A and
B: Shape, origin, and
insertion of the buccinator muscle occupying the lateral region
of the mouth
3,4.
Previously, its fibers intersect with those of the orbicularis muscle and
later are inserted in the mandibular raphe, superiorly in the maxilla and
inferiorly in the branch of the mandible (Figure 1B). It is transposed by the parotid duct at the height
of the second upper molar tooth, slightly above the center of the
muscle3,4.
Arterial irrigation is done through 3 main origins, the buccal artery, and
the branch of the internal jaw that irrigates the posterior half of the
muscle, horizontally from front to back. The anterior portion receives
branches of the facial artery 1 cm lateral to the corner of the mouth,
giving off horizontal branches to the muscle5-9. The third
branch is the posterosuperior alveolar6 branch of the internal maxillary artery that irrigates the
muscle in its superior posterior portion.
There are consistent anastomoses between all these arteries, which can be
found on the lateral surface3,10 of the
muscle or within its fibers. This network also has anastomoses with branches
of the infraorbital artery (Figure 2A)3,10,11.
Figure 2 - A: Arterial supply of the buccinator muscle;
B: Venous supply;
C: Motor
innervation
1.
Figure 2 - A: Arterial supply of the buccinator muscle;
B: Venous supply;
C: Motor
innervation
1.
Venous drainage is rich with some of the arteries that drain into the
pterygoid plexus and then into the internal maxillary vein. Another previous
collector is the facial vein. A venous plexus also surrounds the parotid
duct (Figure 2B)4.
The motor innervation of the buccinator muscle passes through the facial
nerve that emerges near the adipose body of the cheek12,13
from posterior to anterior in the oral plexus (Figure 2C)14,15. This
set gives the possibility of obtaining part of the muscle without
undermining the remaining portion. Sensory innervation of the buccal mucosa
that is adhered to the buccinator muscle is made by branches of the
maxillary nerve.
The buccinator muscle is part of a sphincteric muscular system that includes
the upper constricting muscle of the pharynx and orbicularis muscle, which
facilitates suctioning, whistling, and propulsion of food during chewing. It
also has an influence on the toning of the lips and symmetry of the labial
commissures16.
Obtaining retail
Under general anesthesia, the patient underwent orotracheal intubation fixed
at the median line, in the horizontal dorsal decubitus and Trendelenburg
positions, hyperextended head, the surgeon sitting at her head, and mouth
opened with a static mouth retractor (Rose position). The spindle was
obtained at a maximum of 1.5 cm in width in infancy and 2 cm in adulthood,
from the labial commissure to the mandibular raphe, ending there with the
same width of the center of the flap, and just below the osteo (Figure 3A and B).
Figure 3 - A: Schematic of the spindle flap marking and its
position when rotated (dotted line);
B: The
obtained flap and its extensibility;
C: Marking of
the Y-shaped flap and its future position with rotation;
D: Y-shaped flap and its extensibility
2.
Figure 3 - A: Schematic of the spindle flap marking and its
position when rotated (dotted line);
B: The
obtained flap and its extensibility;
C: Marking of
the Y-shaped flap and its future position with rotation;
D: Y-shaped flap and its extensibility
2.
If the extremity is in Y, the anterior portions advance slightly in the upper
and lower labial mucosa (Figure 3C and
3D). The flap is started from the
angle of the mouth. The scaly mucosa is incised only at the end. Scissors
are then attached, and the muscle attached to the mucosa is removed using
the scissors on the demarcated line, centimeter by centimeter to the
mandibular ramus. Release of the oropharyngeal fascia muscle is easy1,2.
In this procedure, pterygoid plexus veins must be ligated and sectioned. The
adipose body of the cheek will always be exposed and should be compressed
with gauze soaked in adrenaline solution at a concentration of 1:200,000 by
using a retractor. When the flap is in Y, the orbicular artery of the lips
is found early in the divulsion and can be ligated and sectioned. The
posterior vascular pedicle enters the flap in front of raphe in which the
muscle and mucosa remain fixed.
The donor area is closed with absorbable wires with some separate stitches
and then anchored using continuous stitches. To facilitate this procedure,
the opening of the static retractor is reduced. The greasy body of the face
remains in its place of origin.
The point of rotation of the flap obtained is in the raphe, and the arch is
made behind the tuberosity of the maxilla, with the end of the flap reaching
to the anterior region of the hard palate. The flap is extensible, reaching
areas more distant than its original measurement before being obtained
(Figure 3B and 3D).
Palatal stretching
After obtaining the fusiform flap, a transverse incision is made between the
hard and soft palates, releasing the mucosa and musculature between them
until reaching the pedicle base of the raised flap. On the nasal side, the
mucosa is partially detached from the hard palate. The loose musculature is
drawn back toward the posterior pharynx and sutured in the midline point to
point (non-absorbable) until it reaches maximum tension transversely
(muscular V-Y)1,2. In this way the tendency of the soft
palate, besides lengthening, turns backward. The buccinator flap is then
rotated 180º along its axis and sutured over the blown area (Figure 4A-B-C).
Figure 4 - A and
B: Schematic of the obtained
spindle flap and its rotation by 180º.
C: The flap
is rotated and sutured over the bloody area
2.
Figure 4 - A and
B: Schematic of the obtained
spindle flap and its rotation by 180º.
C: The flap
is rotated and sutured over the bloody area
2.
Correction of palatine fistulas
In fistulas of the junction between the hard and soft palates, which are the
most common, the procedure is similar to that for cases of stretching. If
necessary, a mucosal flap in the “book sheet” of the palate is used to cover
the nasal lining. Stretching is always obtained as a consequence of fistula
closure1,2.
The same occurs with previous fistulas. Retractions of the fistula border
make the lining, and the flap in this case in Y closes the fistula and
lengthens the palate (Figure 5A-B-C).
Figure 5 - A, B and
C: Schematic of the
obtained and rotated Y-shaped flap. D: The flap is sutured over
the raw area of the nasal lining of the hard palate and between
the hard and soft palates, lengthening it
2.
Figure 5 - A, B and
C: Schematic of the
obtained and rotated Y-shaped flap. D: The flap is sutured over
the raw area of the nasal lining of the hard palate and between
the hard and soft palates, lengthening it
2.
Closure of the primary palature with stretching
When the soft palate slopes are narrow, closure using the classical
techniques17-19 may result in a short palate,
causing future difficulties in phonation. Under these conditions, it is
desirable to lengthen the palate primarily.
The free edges of the cleft are detached, the nasal mucosa is approached
throughout its length, the hard and soft palate are separated by transverse
incision, and the muscles are sutured in V-Y. A Y-flap is obtained and
rotated 180º on the pedicle. One of the legs covers the hard longitudinal
area of the hard palate and the other suture transversely over the
blistering area between the two palates (Figure 5A-B-C-D)1,2.
RESULTS
Results after 27 years
After 27 years of the initial publication, the author was able to contact
only 6 of the 36 patients with cleft palate treated using a buccinator
muscle flap1. Five had primary
corrections, with the use of a fusiform flap at the beginning of the
experiment in one and a Y flap in four. One of them had a secondary
correction, and one did not have preoperative photographs.
The patient in figure 6A-B-C-D-E, a receptionist, underwent palate correction with
fusiform flap stretching and closure of the soft and hard palates with the
classic technique using palatal flaps. He did not undergo any orthodontic or
phoniatric treatment, despite the mild speech difficulty and hypoplastic
jaw, with collapse to the right already visible in the preoperative period
in childhood.
Figure 6 - A, B, C, D and E: Transforamen
fissure corrected with a spindle flap from the buccinator
muscle.
Figure 6 - A, B, C, D and E: Transforamen
fissure corrected with a spindle flap from the buccinator
muscle.
The patient in figure 7A-B-C-D-E-F-G-H, an economist, underwent initial correction of the lip with
healplasty at 4 months old20,
correction of the palate with a buccinator flap in Y at 1.5 years old, and
rhinoplasty at 16 years old. He attained a normal bite with orthodontics and
partial dentures. He did not undergo phonological treatment, had normal
voice, and slight inversion of the lip projection (Figure 7G).
Figure 7 - A, B, C, D, E, F, G and H:
Transforamen fissure corrected with a Y-shaped flap.
Figure 7 - A, B, C, D, E, F, G and H:
Transforamen fissure corrected with a Y-shaped flap.
The patient in figure 8 A-B-C-D-E-F-G-H, an accountant, did not undergo orthopedic treatment of the
jaw or orthodontics. He lost some teeth due to bad conservation that were
replaced, speech and bite normal. In the distension of the facial region of
the buccinator, he could not project to the right (Figure 8F), but he did not mention any functional
disturbance for this reason.
Figure 8 - A, B, C, D, E, F, G and H:
Post-foramen fissure corrected with a Y-shaped flap.
Figure 8 - A, B, C, D, E, F, G and H:
Post-foramen fissure corrected with a Y-shaped flap.
The patient in figure 9 A-B-C-D-E, a plastic surgeon, underwent lip surgery at 4 months
(Millard’s technique) with 1.5 years of the palate with a Y buccinator flap,
and rhinoplasty after puberty. He underwent only orthodontic treatment, had
a normal bite and voice.
Figure 9 - A, B, C, D and E: Transforamen
fissure corrected with a Y-shaped flap.
Figure 9 - A, B, C, D and E: Transforamen
fissure corrected with a Y-shaped flap.
The patient in figure 10 A-B-C-D-E, a tourism businesswoman, underwent a secondary
stretching after correction of the soft palate (incomplete post-foramen
fissure) with the simple approach technique, resulting in fistula, which was
corrected, and palate elongation. He underwent orthopedic, and speech and
hearing treatments to attain normal voice and bite.
Figure 10 - A, B, C, D and E: Palate elongation
and correction of a fistula with a spindle flap between the soft
and hard palates.
Figure 10 - A, B, C, D and E: Palate elongation
and correction of a fistula with a spindle flap between the soft
and hard palates.
DISCUSSION
The buccinator muscle flap, besides its uses in fissures and fistulas, can be
used in any situation in bloody intrabuccal areas, such as tumor resections,
osteomyelitis, or traumatic losses. Two flaps can be used simultaneously, one
for the nasal lining and the other for the oral mucosa. In case of failure of
one, the other can still survive.
In cases of postoperative fistula, the tissues become fibrous, rigid, and
retractable, making it impossible to obtain adequate, movable, and long palates
with good function without the use of new tissues such as the flap
described.
Irrigation of the buccinator muscle with its anterior pedicle can repair labial
defects of the mucosa, traumatic wounds, or tumor post-resection sites21.
Using the flap leaves the nasal lining and flap sutures in different positions,
making it difficult for new fistulas to appear.
The transposition of the flap and 180º rotation behind the maxillary tuberosity
always leaves a cicatricial bridle that does not lead to functional
consequences. It can be corrected at any time after the integration of the flap
with a mini zetaplasty.
It was described in 1989 that the donor area of the flap was not modified, but
one of the patients contacted (Figure 8F)
presented a reduction in the extensibility of the cheek, without causing any
oral function impairment or maxillo-mandibular alterations. His medical record
indicated that the flap was wide, which can be seen in figure 8C, and that it was difficult to close the donor
area.
In the original description, he commented on the lymphatic edema and the muscle
volume, and that the massage caused by the movements of the tongue reduced it,
which was verified to be true by the other patients contacted.
Maxillary growth was practically normal in the primary patients contacted, where
the none of the palatal flaps were detached and only orthodontic treatment was
required. One patient (Figure 6A-E) did not undergo any treatment, and the
fissured side evolved with collapse of the arch on that side, which was already
visible in the preoperative photograph in childhood.
As for speech, even those who did not receive speech therapy presented minimal
changes in their voices22. This was
demonstrated in 6 cases that were surgically treated using the described
technique. The patient in figure 11A-B-C-D-E-F-G underwent surgery using the traditional
techniques17,18 and had 27-year postoperative results,
without maxillary orthodontic and orthodontic treatments, which were the
standard treatment before the advent of the buccinator muscle flap. In addition
to dental misalignment and hypodevelopment of the maxilla, he had great
difficulty speaking due to nasal exhaust.
Figure 11 - A, B, C, D, E, F and G: Operation with
the classic Veaux-Langenbeck technique. In the 28th
postoperative year, significant changes were observed in three areas
in a patient who did not undergo orthopedic, orthodontic, and
phoniatric treatments.
Figure 11 - A, B, C, D, E, F and G: Operation with
the classic Veaux-Langenbeck technique. In the 28th
postoperative year, significant changes were observed in three areas
in a patient who did not undergo orthopedic, orthodontic, and
phoniatric treatments.
The attempt contact these patients started from the time of entry into plastic
surgery residency at the Base Hospital of the State Medical School of São José
do Rio Preto. The patient in figure 9A-B-C-D-E was attended to by the author from the
first day of life.
Historically, the study of flaps started from a colloquial debate between
friends, the author and Chem23, when the
former manifested the impossibility of correcting palatal fistulas with a
microsurgical flap from the pedicle artery of the foot pedicle owing to the
difficulties that the technique presented for surgeons who did not perform
microsurgery, as the author himself. He expressed the need to look for other
solutions, complementing previous studies that sought to obtain better function
and closure of the palate with minimum sequelae24-28.
CONCLUSION
Although statistically insignificant, the verification of cases over a mean
period of 27 years shows that the 6 patients contacted had normal or near-normal
maxillary growth and almost normal speech even without adequate
phono-audiological treatment. One patient had poor extensibility of the cheek
because the flap was too wide.
COLLABORATIONS
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ARB
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Analysis and/or interpretation of data.
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1. Hospital de Base, Faculdade Estadual de
Medicina de São José do Rio Preto, São José do Rio Preto, SP,
Brazil.
Corresponding author: Antonio Roberto
Bozola
Av. Brigadeiro Faria Lima, 5416 - Vila São Pedro
São José do
Rio Preto, SP, Brazil Zip Code 15090-000
E-mail: ceplastica@hotmail.com
Article received: November 24, 2017.
Article accepted: February 19, 2018.
Conflicts of interest: none.
