1266
regions. We thank Ferrari et al for their interesting contri-
bution to the use of the BMMF.
HRISTO SHIPKOV, MD, PHD
Plovdiv, Bulgaria, and Lyon, France
PENKA STEFANOVA, MD, PHD
BOJIDAR HADJIEV, MD, PHD
ANGEL UCHIKOV, MD, PHD
KAREN DJAMBAZOV, MD, PHD
Plovdiv, Bulgaria
ALI MOJALLAL, MD, PHD
Lyon, France
References
1. Ferrari S, Ferri A, Bianchi B, et al: Reconstructing large palate
defects: The double buccinator myomucosal island flap. J Oral
Maxillofac Surg 68:924, 2010
2. Bozola AR, Gasques JA, Carriquiry CE, et al: The buccinator
musculomucosal flap: Anatomic study and clinical application.
Plast Reconstr Surg 84:250, 1989
3. Shipkov C, Simov R, Bukov Y, et al: The nasolabial flap and the
buccinator flap. Anatomic study and 2 case reports. Ann Chir
Plast Esthet 48:152, 2003
4. Zhao Z, Li S, Yan Y, et al: New buccinator myomucosal island
flap: Anatomic study and clinical application. Plast Reconstr Surg
104:55, 1999
5. Hill C, Riaz M, Leonard AG: A technique for repair of the
“unrepairable” cleft palate. Br J Plast Surg 52:658, 1999
doi:10.1016/j.joms.2010.12.019
In reply:—We really appreciate the positive comments pro-
vided by Shipkov et al on our previously published article
on the buccinator myomucosal flap.1 The authors well out-
lined some of the major advantages of this flap: the constant
and reliable vascular anatomy, its wide range of rotation, the
possibility of harvesting the flap independently of the dental
status of the patient, and the possibility of harvesting 2
simultaneous buccinator flaps for larger defects.
We would like to underline other advantages of this
technique: the relatively fast and reliable harvesting of the
flap; the possibility of also using the flap in patients under-
going neck dissection (when sacrifice of the facial artery
may exclude other techniques); the very low donor-site
morbidity, thanks to the possibility of using the buccal fat
pad for the reconstruction of the donor site, thus reducing
scar retraction and trismus (especially after radiation ther-
apy); and its extreme versatility, with possible applications
not only for the reconstruction of the palate but also of the
tongue, oropharynx, and cheek.2
We would also like to underline that the use of posterior,3
anterior,4 or island buccinator myomucosal5 flaps is largely
underestimated in the international literature, especially if
compared with the large number of published articles de-
scribing free flap techniques. We currently use buccinator
myomucosal flaps in a large number of our patients with
moderate defects of the oral cavity,6 with optimal results in
terms of both form and function.7
We commend the analysis of the buccinator myomucosal
flap proposed by Shipkov et al, and we hope that it might
encourage all the readers to increase their application of
this technique, which should be considered today one of
the indispensable instruments of the head and neck recon-
structive surgeon.
LETTERS TO THE EDITOR
SILVANO FERRARI, MD
ANDREA FERRI, MD
BERNARDO BIANCHI, MD
CHIARA COPELLI, MD
ENRICO SESENNA, MD
Maxillo-Facial Surgery Division
University Hospital of Parma
Parma, Italy
References
1. Ferrari S, Ferri A, Bianchi B, et al: Reconstructing large palate
defects: The double buccinator myomucosal island flap. J Oral
Maxillofac Surg 68:924, 2010
2. Ferrari S, Ferri A, Bianchi B, et al: A novel technique for cheek
mucosa defect reconstruction using a pedicled buccal fat pad
and buccinator myomucosal island flap. Oral Oncol 45:59, 2009
3. Bozola AR, Gasques JA, Carriquiry CE, et al: The buccinator
musculomucosal flap: Anatomic study and clinical application.
Plast Reconstr Surg 84:250, 1989
4. Pribaz J, Meara G, Wright S, et al: Lip and vermillion reconstruc-
tion with the facial artery muscolomucosal flap. Plast Reconstr
Surg 105:864, 2000
5. Ferrari S, Balestreri A, Bianchi B, et al: Buccinator myomucosal
island flap for reconstruction of the floor of the mouth. J Oral
Maxillofac Surg 66:394, 2008
6. Bianchi B, Ferri A, Ferrari S, et al: Myomucosal cheek flaps:
Applications in intraoral reconstruction of three different tech-
niques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
108:353, 2009
7. Ferrari S, Ferri A, Bianchi B, et al: Donor site morbidity using the
buccinator myomucosal island flap. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2010 Aug 31 [Epub ahead of print]
doi:10.1016/j.joms.2010.12.018
NASAL SPLINT DESIGNED USING
3-DIMENSIONAL PLANNING
To the Editor:—Nasal splints are used after primary cleft
surgery to maintain the alae nasi and the septum in a satisfac-
tory position during the postoperative period.1 By ensuring
nasal breathing, they also play a major functional role in cranio-
facial growth.2,3 Splints exist in innumerable different models
but are all formed by 2 hollow arms connected by a columellar
bridge. Silicon splints are available commercially at high prices
but are not affordable to many surgery departments. Access to
high-quality silicon and 3D technologies necessary to build
splints locally is also a major problem. Several alternatives to
commercial splints have been described but all lack either
calibration possibilities or necessitate adhesion devices such as
tape.4,5 We have designed a new type of nasal splint using
3-dimensional computed tomography scan-based planning
(Fig 1A,B) to produce a mold for several standard sizes adapted
to primary and secondary cleft surgeries and adult rhinoplasty
(Fig 1C). The shape of the splint closely matches the inner
contours of the average nasal cavity of children and adults at
different ages. The splint does not require any fixation device,
and its insertion is very easy (Fig 1D).
Fine adjustments can be made by reshaping the arms
and the columellar bridge. Our aim was to provide a
ready-to-use, low-priced, and high-quality splint to cleft
surgery departments across the Russian territory and in
countries in which the local production of optimal qual-
ity splints is difficult. We believe that this device will
contribute to obtain better results after nasal reconstruc-
LETTERS TO THE EDITOR
FIGURE 1. A,B, Soft silicon nasal splint designed using 3-dimensional planning, (C) available in standard and optimal quality, in sizes
adapted to cleft rhinoplasty and nose reconstruction, (D) without the need for external contention, intended to be distributed in order to
promote functional treatment plans.
tion in centers, which do not have access to specialized
prosthesists.
The splint described in our letter is manufactured by us; it
is a nasal splint for use after rhinoplasty, and its Food and Drug
Administration approval status is investigational.
ALEXANDRE L. IVANOV, MD
Moscow, Russia
ROMAN H. KHONSARI, MD
Nantes, France
References
1. Yeow VK, Chen PK, Chen YR, et al: The use of nasal splints in
the primary management of unilateral cleft nasal deformity. Plast
Reconstr Surg 103:1347, 1999
2. Markus AF, Delaire J: Functional closure of cleft lip. Br J Oral
Maxillofac Surg 31:281, 1993
3. Talmant JC, Lumineau JP, Rousteau G: Prise en charge des fentes
labiomaxillo-Palatines dans l’équipe du docteur Talmant à
Nantes. Ann Chir Plast Esthet 47:116, 2002
4. Tan O, Atik B, Vayvada H: A new custom-made nostril retainer: The
rubber of infusion set. Plast Reconstr Surg 117:1053, 2006
5. Özyazgan I, Eskitaşçioğlu A: New reshaped nostril retainer. Plast
Reconstr Surg 105:804, 2000
doi:10.1016/j.joms.2010.12.012
1267
KERATOCYSTIC ODONTOGENIC TUMOR VERSUS
ODONTOGENIC KERATOCYST–THE ISSUE OF
ADEQUATE NOMENCLATURE
To the Editor:—Recently, Boffano et al1 published an inter-
esting article titled “Keratocystic odontogenic tumor (odon-
togenic keratocyst): Preliminary retrospective review of ep-
idemiologic, clinical, and radiologic features of 261 lesions
from University of Turin.” We read this article with great
interest and compliment the authors for their thorough
clinical analysis, and although their study could be of im-
portance, we have several considerations when interpreting
their findings. In response, we would like to highlight
several important issues.
First, the keratocystic odontogenic tumor (KCOT), for-
merly classified as a cystic lesion called odontogenic kerato-
cyst (OKC), was subsequently reclassified in 2005 by the
World Health Organization Working Group2 as a neoplas-
tic lesion. The microscopic criterium for KCOT clearly
indicates that the spectrum of this tumor consists only of
jaw lesions with a characteristic lining consisting of para-
keratinized stratified squamous epithelium.2 OKC previ-
ously included both parakeratinized and orthokeratinized
variants. Designation of an OKC is currently reserved for
cystic jaw lesions that are lined solely by orthokeratinizing
epithelium, and they do not form a part of the range of the
KCOT.2 In accordance with the current World Health Or-