TECHNICAL NOTES
J Oral Maxillofac Surg
66:394-400, 2008
Buccinator Myomucosal Island Flap for
Reconstruction of the Floor of the Mouth
Silvano Ferrari, PhD,* Alfredo Balestreri, MD,†
Bernardo Bianchi, MD,‡ Alessandra Multinu, MD,§
Andrea Ferri, MD,㛳 and Enrico Sesenna, PhD¶
Mucosal defects of the oral cavity, particularly those
of the floor of the mouth and associated with onco-
logic resection, may be closed with skin grafts or free
flaps. Skin grafts offer the most immediate reconstruc-
tive option,1 but they are rarely used to fill defects in
the oral floor because they require stable fixation to
the recipient site without collection of blood or se-
rous material between the 2 surfaces.
Skin grafts require a compressive dressing, which is
difficult to place on a mobile structure such as the
tongue or oral floor. Saliva plays a role in the choice of
reconstruction approach because salivary stagnation
in the mouth can lead to maceration of the graft itself,
compromising the outcomes of reconstructive sur-
gery. Scarring and tissue retraction during the healing
process, and especially during radiotherapy, lead to
esthetic defects and further reduce mobility; anky-
loglossia may result.
Several types of local or locoregional flaps also have
been proposed.2 These include myocutaneous flaps,
such as pectoral or trapezius flaps, which require
repositioning of the patient on the operating table
and result in morbidity at the donor site. Moreover,
they often are too thick and lead to functional and
esthetic defects, prolonged hospitalization, and in-
creased patient discomfort. Muscular flaps, like tem-
Received from the Department of Maxillo-Facial Surgery, University
and Hospital of Parma, Parma, Italy.
*Associate Professor.
†Resident.
‡Assistant-in-Chief.
§Resident.
㛳Resident.
¶Chief.
Address correspondence and reprint requests to Dr Balestreri:
Department of Maxillo-Facial Surgery, Head and Neck Division,
University and Hospital of Parma, Via Gramsci 14, 43100 Parma,
Italy; e-mail: alfredive@hotmail.com
© 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6602-0034$34.00/0
doi:10.1016/j.joms.2006.10.036
394
poralis3 or masseter flaps, are often indicated for the
treatment of patients with posterior maxillary defects,
but difficulty is often encountered in transposing such
a flap to the anterior part of the mouth. These flaps
also may lead to esthetic defects of the face and can
produce functional limitations such as trismus.
A platysma myocutaneous flap4 may be indicated in
patients who require reconstruction of small and me-
dium-sized defects of the oral cavity. The platysma
flap is a reliable local flap with a generous blood
supply that allows primary closure; it is of appropriate
thickness for such reconstructions. However, it may
lead to scar retraction in the neck and does not allow
good mobility, which is very important for recon-
struction of the floor of the mouth.
Martin et al first described the submental island flap
in 1993.5 The safety of this surgical technique and the
associated reduction in postoperative complications
make it a better option than the platysma myocutane-
ous flap. The submental island flap has disadvantages,
however, such as its hair-bearing nature in males,
especially when used for intraoral defects on the floor
of the mouth. It is also contraindicated in reconstruc-
tion that is undertaken after the resection of intraoral
malignancies that are suspected of having metasta-
sized to the submental lymph nodes.
Another group of flaps proposed for use in treat-
ing defects of the oral floor consists of fasciocuta-
neous, myocutaneous, and muscular free flaps,6 such
as radial forearm, lateral upper arm, latissimus dorsi,
gracilis musculocutaneous, and perforator flaps. Al-
though several authors consider these good recon-
struction options, these flaps may lead to morbidity at
the donor site and require longer, more laborious
surgical procedures involving microsurgery. In addi-
tion, the tissue type may provide a contraindication,
in that these flaps are taken from outside the oral
cavity and often produce an unnecessarily large amount
of tissue.
Recently, several authors have focused attention on
the use of different types of flaps that use the intraoral
lining of the cheek. This is an ideal donor site because
of the minor negative effects on cheek and oral cavity
FERRARI ET AL 395

functions and the rich vascularization of the oral mu-

cosa, which facilitates flap healing.
In 1999, Zhao et al7 introduced the buccinator
myomucosal island flap (BUMIF). It is a useful, versa-
tile technique for correcting defects in any part of the
oral cavity, with good results and modest morbidity.
The buccinator muscle has a rich vascular pattern that
can be used for flap harvesting. Zhao described 2
different types of buccinator myomucosal island flaps:
one based superiorly, supplied by the distal portion of
the facial artery via the anterior buccal branches of
the facial artery, and the other, based on a flap sup-
plied by the buccal artery and the posterior buccal
branch of the facial artery. The former is a combina-
tion of the buccinator flap reported by Carstens et al
in 19918 and the superiorly based facial artery mus-
culomucosal flap (FAMM) reported by Pribaz et al in
1992.9 The latter is a refinement of the technique
reported by Bozola et al10 of making a deep flap to the
pterygomandibular raphe and into the palate.
A third type of BUMIF, which may be classified as
an inferiorly based approach, was described by Zhao
et al in 200311 for partial tongue reconstruction. We
suggest its use for reconstructing the floor of the mouth
with a tunnel under the mandibular arch. We describe
here our clinical experience based on the use of
FIGURE 1. Flap design and perfusion.
BUMIF in 5 patients who underwent oncologic resec-
tion in areas of the oral cavity involving the oral floor. Ferrari et al. Buccinator Myomucosal Island Flap for Mouth
Reconstruction. J Oral Maxillofac Surg 2008.

Surgical Dissection
After the orifice of the Stensen’s duct in the cheek
is identified, an incision is made about 1 cm inferiorly
to form the superior margin of the flap. Then, to
produce a fusiform shape, the flap is designed (Fig 1)
on the mucosa extending anteriorly from the mandib-
ular raphe to the buccal commissure. The inferior
margin of the flap may extend a few centimeters
under the superior margin, depending on the size of
the defect. The anterior margin may be limited to the
area of the oral commissure, or it can extend into 2
branches through removal of tissue from the superior
and inferior lips. During harvesting and flap separa-
tion, the proximal ends of the facial vessels are su-
tured onto the upper margin of the flap for their
protection. The facial artery and vein are followed
inferiorly and laterally during the dissection. The pos-
terior buccal branch of the facial artery then is ligated
and cut, and the facial artery and vein are dissected
free from the surrounding structures, with care taken
to avoid damage to the marginal branch of the facial
nerve. In this way, the resultant flap is composed of
mucosa and submucosa, buccinator muscle, and a
portion of the orbicularis muscle near the oral com-
missure with a reliable pedicle.
The flap is tunneled between the cheek and the
external side of the mandible, and then through the
mylohyoid muscle into the oral cavity, to avoid dam-
age to the vascular pedicle during mastication in den-
tate patients. The donor site may be closed primarily
without compromise of oral cavity function. If the
donor site is larger than 3 cm in diameter, it should be
closed by skin grafting or by transposition of a portion
of the buccal (Bichat’s) fat pad, which later undergoes
re-epithelialization.
Materials and Methods
Between January 2003 and May 2005, this recon-
struction method was performed in 5 patients who
had undergone oncologic resection involving the oral
floor (Table 1). Two patients were female and 3 were
male and they ranged in age from 49 to 82 years. In 2
cases, resection involved only the oral floor; in 2
cases, the defect extended to the border of the
tongue; in 1 case, it extended to the lateral oral floor.
The reconstruction option used in each patient was
based on the dimensions of the tumor, which did not
exceed 4 cm in cases described in this article (T2).
396 BUCCINATOR MYOMUCOSAL ISLAND FLAP FOR MOUTH RECONSTRUCTION

Table 1. LIST OF PATIENTS, SITES, STAGING AND GRADING OF LESIONS, SURGICAL PROCEDURES, AND LOCAL
COMPLICATIONS

Age, Local
Patients yr Site Grading Histology Surgery Complications

C.V. 49 Right oral floor T2 N0 M0 Squamous cell Right oral floor resection ⫹ None
extending to carcinoma G2 Partial glossectomy ⫹ Right
tongue border selective neck dissection
F.G. 59 Right oral floor T2 N0 M0 Squamous cell Right oral floor resection ⫹ None
extending to carcinoma G1 Partial glossectomy ⫹ Right
tongue border selective neck dissection
C.S. 82 Left oral floor T2 N0 M0 Adenoid cystic Resection of the left oral None
carcinoma floor
R.I. 61 Anterior oral floor T2 N0 M0 Squamous cell Anterior oral floor resection None
carcinoma G2 ⫹ Right selective neck
dissection
A.E. 49 Anterior oral floor T2 N0 M0 Squamous cell Anterior oral floor resection Sialoadenitis of
carcinoma G2 ⫹ Left selective neck right
dissection ⫹ Right sentinel submandibular
lymph node gland
Ferrari et al. Buccinator Myomucosal Island Flap for Mouth Reconstruction. J Oral Maxillofac Surg 2008.

Results and right selective neck dissection; reconstruction was per-

All flaps were harvested and transposed success-
fully, with no resultant infection or dehiscence. In
addition, functional (Figs 2, 3) and esthetic results
(Fig 4) were satisfactory. One female patient devel-
oped sialoadenitis of the residual submandibular
gland and was treated with sialoadenectomy.
Report of Cases
PATIENT 1
In this female patient (61 years old) who had squamous
cell carcinoma G2 of the anterior floor of mouth, staging
was T2 N0 M0 (TNM, tumor node metastasis) (Fig 5). The
patient was treated by resection of the anterior oral floor
formed with a BUMIF taken from the right cheek (Figs 6, 7).
PATIENT 2
In this male patient (49 years old) who had squamous cell
carcinoma G2 of the right oral floor extending to the tongue
border, staging was T2 N0 M0 (Fig 8). The patient under-
went right oral floor resection, partial glossectomy, and
right selective neck dissection. Reconstruction was per-
formed with a BUMIF taken from the right cheek (Fig 9).
Discussion and Conclusions
Small or moderate defects of the floor of the mouth
that result from any type of resection, especially in

FIGURE 3. Postoperative view of reconstruction performed with buc-

FIGURE 2. Postoperative view of reconstruction performed with a cinator myomucosal island flap (BUMIF). Mobility of the tongue and
buccinator myomucosal island flap (BUMIF). oral floor is preserved.
Ferrari et al. Buccinator Myomucosal Island Flap for Mouth Ferrari et al. Buccinator Myomucosal Island Flap for Mouth
Reconstruction. J Oral Maxillofac Surg 2008. Reconstruction. J Oral Maxillofac Surg 2008.
FERRARI ET AL 397

FIGURE 5. Preoperative view of a lesion on the anterior floor of the

mouth.
Ferrari et al. Buccinator Myomucosal Island Flap for Mouth
Reconstruction. J Oral Maxillofac Surg 2008.

oncologic patients, must not be underestimated be-

cause they may produce functional limitations in
cases of inadequate reconstruction. To reconstruct
the defect, the tissue used should have the same
characteristics of consistency and thickness as the
components resected or lost. At present, such recon-
structions may be approached with the use of local or
locoregional flaps, depending on the type of defect
that is being treated. To treat small oral defects, many
authors suggest the tongue as a source of well-vascu-
larized mucosa. This approach may lead to functional
defects, and critical activities of the tongue, especially
phonation and deglutition, must not be impeded.
The nasolabial flap12,13 has been widely used for
reconstruction of oral defects, especially in oncology,
because it can be rotated and turned to fill various

FIGURE 4. Esthetic results: preoperative and postoperative views of

the face. No interference with facial harmony is noted. FIGURE 6. Intraoperative view during flap harvesting.
Ferrari et al. Buccinator Myomucosal Island Flap for Mouth Ferrari et al. Buccinator Myomucosal Island Flap for Mouth
Reconstruction. J Oral Maxillofac Surg 2008. Reconstruction. J Oral Maxillofac Surg 2008.
398 BUCCINATOR MYOMUCOSAL ISLAND FLAP FOR MOUTH RECONSTRUCTION
FIGURE 7. Intraoperative view: donor site and reconstruction of the
floor of the mouth.
Ferrari et al. Buccinator Myomucosal Island Flap for Mouth
Reconstruction. J Oral Maxillofac Surg 2008.
defects. Despite their versatility in reconstruction of
the oral cavity, nasolabial flaps have some disadvan-
tages. The tissues are very different from those re-
sected, and these flaps are not indicated in young
FIGURE 8. Preoperative view of the lesion of the right oral floor
extending to the tongue border.
Ferrari et al. Buccinator Myomucosal Island Flap for Mouth
Reconstruction. J Oral Maxillofac Surg 2008.
FIGURE 9. Intraoperative view during flap harvesting and
transposition.
Ferrari et al. Buccinator Myomucosal Island Flap for Mouth
Reconstruction. J Oral Maxillofac Surg 2008.
patients or those with previous scars that interrupt
the axial vascularization of the flap. In addition, the
donor site may heal with scar retraction, which may
alter facial harmony, even if residual scarring is con-
cealed in the nasolabial fold. If this tension is directed
from the apex toward the internal canthus of the eye,
ectropion may result.
The buccal (Bichat’s) fat pad14-16 has been used as
the donor site for flaps vascularized by internal max-
illary, superficial temporal, and small branches of the
facial arteries. These flaps offer several advantages,
including intraoral harvesting, an easy and relatively
fast surgical procedure, low morbidity, and the capa-
bility of these tissues to re-epithelialize within a few
weeks. However, they also have the following limita-
tions: 1) they can be used only for limited defects,
principally those in the posterior oral cavity, and they
are not indicated for filling of oral floor defects; 2) flap
tissues are very different from lost tissues; and 3)
esthetic results are limited by the possibility that a
depression may be formed in the cheek.
Recently, several authors suggested the use of flaps
that contain both muscle and mucosal tissue. In 1989,
Bozola et al10 proposed a buccinator musculomucosal
flap perfused by the buccal artery, with a pivot lo-
cated in the cheek mucosa posterior to the maxillary
tuberosity. However, this flap can be used only for
defects of the hard and soft palate or of the mandible
up to the level of the canine. Rayner and Arscott in
198717 and Tezel in 1998 and 200218,19 proposed the
use of a buccal musculomucosal flap pedicled on the
internal side of the oral commissure, principally for
reconstruction of vermilion defects that initially had
maximum dimensions of 1 ⫻ 3 cm that were later
increased to 3 ⫻ 6 cm (by Tezel).
FERRARI ET AL
With use of a branch of the facial artery with a pivot
at the corner of the mouth, Ono et al20 created a flap
that measured 1.5 ⫻ 5 cm; it was used to cover
defects in the inferior portion of the oral cavity. In
1991, Carstens et al8 proposed a myomucosal bucci-
nator flap, measuring up to 7 ⫻ 5 cm, that was based
on the facial artery and vein. Cannulation of the Stens-
en’s duct is required, as is nasolabial access for good
mobilization. An unesthetic cheek scar or limited
opening of the mouth may result.
In 1992, Pribaz et al9 proposed an axial musculo-
mucosal flap planned along the course of the facial
artery (FAMM). FAMM used for small or moderate
defects of the floor of the mouth is an excellent
reconstruction option that is easy to perform, is faster
than other procedures, and has a high rate of suc-
cess.21 Morbidity at the donor site is minimal, and the
donor defect is closed through apposition of the com-
bined margins without compromise of oral cavity
function. The flap is lifted from the intraoral side of
the cheek; no unesthetic cutaneous scarring or alter-
ation of the cheek profile is noted.
Despite its versatility, simplicity, and good esthetic
results, the FAMM flap has some disadvantages that
cannot be ignored. Its main disadvantage is the need
for a secondary procedure 10 days later to divide the
flap pedicle. In addition, the dentition may cause
discomfort because of the need for a bite block in
patients with their own dentition to avoid damage to
the peduncle incurred during mastication. This flap is
harvested along the course of the facial artery, with a
limited amount of muscle, and its shape develops
mainly along a longitudinal axis. Thus, it is often
inadequate for filling defects of the oral floor. Conse-
quently, a FAMM must be taken from each cheek.
To solve problems related to the use of FAMM,
Zhao et al7 proposed use of the BUMIF, based poste-
riorly or superiorly. The former is designed as an
island based on the buccal artery, which comes from
the internal maxillary artery, and the latter is based on
the posterior buccal branch of the facial artery, the
buccal venous plexus, and the nerves that innervate
the buccinator. These vessels are fairly constant, and
preoperative tests are not considered necessary. The
flap that is located superiorly should be considered a
variation of the FAMM that is based on the distal
portion of the facial artery through the anterior buc-
cal branches via retrograde flow.
These flaps never appear congested because of the
rich buccinator venous plexuses that drain posteriorly
into the pterygoid plexus and converge on the facial
vein anteriorly.22
We also used a third type of BUMIF, which can be
defined as inferiorly based and was described by Zhao
in 200311 for partial tongue reconstruction. We pro-
pose that it should be used to reconstruct the floor of
399
the mouth via a tunnel under the mandibular arch. In
our experience, a limited tongue defect can be man-
aged with direct closure because of the good compli-
ance of the muscular tongue tissue; thus, removal of a
flap from the buccinator muscle is not necessary.
When this type of closure leads to severe functional
limitation, we suggest the use of thin fasciocutaneous
free flaps, such as a forearm free flap. In our experi-
ence, the primary importance of reconstruction to
repair defects of the floor of the mouth must be
maintained, given the importance of this area in oral
function and tongue mobility.
The BUMIF may find many applications because of
its features: no secondary procedure is needed to
divide the flap pedicle, and the presence of a denti-
tion does not represent a contraindication because a
tunnel is made for the flap. Creation of this tunnel,
which must be sufficiently large to ensure mobility of
the flap, is a laborious process. Depending on the
surgeon’s experience, the procedure may not be very
difficult and may present little or no risk. During neck
dissection, the facial vessels are followed and freed
externally, as well as internally within the cheek.
Then, 2 tunnels must be created and connected: the
first one between the cheek and the external side of
the mandible, and the second one through the mylo-
hyoid muscle and the internal mandibular perios-
teum. During this procedure, care must be taken to
identify, protect, and dissect the marginal mandibular
nerve because trauma may lead to dysfunction. Care
also must be taken to avoid metastatic lymph node
dissemination through fine skeletonization of the fa-
cial vessels. The facial artery is meticulously pre-
served during neck dissection, and radical oncologic
surgery is not compromised. Given the lack of visibil-
ity during tunnel creation for the flap, the surgeon
may wear a headlamp for better illumination.
The BUMIF offers the advantages of FAMM, such as
very low morbidity at the donor site, good esthetic
and functional results due to the similarity between
the flap and resected tissues, and conservation of
muscular innervation to reduce atrophy. This partial
atrophy may be useful; within a few days, the muscu-
lar tissues become thinner and the mucosa expands,
producing improved functional results. The flap is
used to correct not only defects of the oral floor but
also those extending to other parts of the oral cavity,
such as the border of the tongue and the lateral oral
floor. Moreover, the donor site may be closed without
skin grafts by bringing the margins together.
We also suggest that the sublingual gland should be
removed to avoid trauma that may lead to postoper-
ative complications, and to reduce obstacles intro-
duced during creation of the tunnel. If a unilateral
neck dissection is performed, the contralateral Whar-
ton duct also must be cannulated to avoid chronic
400 BUCCINATOR MYOMUCOSAL ISLAND FLAP FOR MOUTH RECONSTRUCTION
sialoadenitis. Partial retraction of the lip and cheek
may occur, but because of the nature of the tissue,
this is only a temporary complication. The facial vein
was identified and conserved in 1 of our cases, but not
in the other 4. Despite this choice, no evidence of flap
congestion has been observed, because of the very
rich submucosal venous plexus and the amount of
mucosal tissue removed.
Because of its capability to yield optimal results
functionally and esthetically, we believe that the
BUMIF represents a very good option for treating
patients with small and moderate defects of the floor
of the mouth.
References
1. Garcia-Penin A, Montalvo-Moreno JJ, Barrenechea-Arana JM, et
al: Primary reconstruction of the oral cavity using a skin graft
after oncologic surgery. Rev Stomatol Chir Maxillofac 93:381,
1992
2. Baker SR: Regional flaps in facial reconstruction. Otolaryngol
Clin North Am 23:925, 1990
3. Cordeiro PG: The temporalis flap revisited on its centennial:
Advantages, newer uses, and disadvantages. Plast Reconstr Surg
98:980, 1996
4. Peng W, Zhang F, Zhao H: Two designs of platysma myocuta-
neous flap for reconstruction of oral and facial defects follow-
ing cancer surgery. Int J Oral Maxillofac Surg 34:507, 2005
5. Martin D, Pascal JF, Baudet J, et al: The submental island flap:
A new donor site. Anatomy and clinical applications as a free or
pedicle flap. Plast Reconstr Surg 92:867, 1993
6. Urken ML, Sullivan MJ, Cheney ML: Atlas of Regional and Free
Flaps for Head and Neck Reconstruction. New York, Raven
Press, 1995
7. Zhao Z, Li S, Yan Y, et al: New buccinator myomucosal island
flap: Anatomic study and clinical application. Plast Reconstr
Surg 104:55, 1999
8. Carstens MH, Stofman GT, Sotereanos GC: The buccinator
myomucosal island pedicle flap: Anatomic study and case re-
port. Plast Reconstr Surg 88:39, 1991
9. Pribaz JJ, Stephens W, Crespo L, Gifford G: A new intraoral flap:
Facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg
90:421, 1992
10. Bozola AR, Gasques JAL, Carriquiry CE, Cardoso de Oliveira M:
The buccinator musculomucosal flap: Anatomic study and clin-
ical application. Plast Reconstr Surg 84:250, 1989
11. Zhao Z, Zhang Z, Li Y, et al: The buccinator musculomucosal
island flap for partial tongue reconstruction. J Am Coll Surg
196:753, 2003
12. Uglesic V, Virag M: Musculomucosal nasolabial island flap for
floor of mouth reconstruction. Br J Plast Surg 48:8, 1995
13. Rose EH: One stage arterialized nasolabial island flap for floor
of mouth reconstruction. Ann Plast Surg 6:71, 1981
14. Dean A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M: The
buccal fat pad flap in oral reconstruction. Head Neck 23:383,
2001
15. Zhang HM, Yan YP, Qi KM, Wang JQ, Liu ZF: Anatomical
structure of the buccal fat pad and its clinical application. Plast
Reconstr Surg 109:2509, 2002
16. Tideman H, Bosanquet A, Scott J: Use of the buccal fat pad as
a pedicled graft. J Oral Maxillofac Surg 44:435, 1986
17. Rayner CR, Arscott GD: A new method of resurfacing the lip.
Br J Plast Surg 40:454, 1987
18. Tezel E, Numanoglu A, Celebiler O, Byramicili M: Commissure-
based buccal mucosal flap. Plast Reconstr Surg 101:1223, 1998
19. Tezel E: Buccal mucosal flaps: A review. Plast Reconstr Surg
109:735, 2002
20. Ono I, Gunji H, Tareshita T, Sanbe N: Reconstruction of defects
of the entire vermilion with a buccal musculomucosal flap
following resection of malignant tumors of the lower lip. Plast
Reconstr Surg 100:422, 1997
21. Ferrari S, Caradonna L, Bianchi B, Balestrieri A, Sesenna E:
Facial artery musculomucosal flap in reconstruction of the oral
cavity. Riv Ital Chir Max-Fac 15, 2004
22. Abou C, Beziat JL, Torossian JM: Reconstruction of the mouth
floor using a musculo-mucosal buccinator flap supplied by
facial vessels: Report of ten cases. Ann Chir Plast Esteth 43:252,
1998