Lip and Vermilion Reconstruction with theFacial Artery Musculomucosal FlapJulian J. Pribaz, M.D., John G. Meara, M.D., D.M.D., Sean Wright, M.D., Jeffrey D. Smith, M.D.,Willie Stephens, D.D.S., and Karl H. Breuing, M.D.Boston, Mass.

The lips are a complex laminated structure. When lostthrough injury or disease, they present a complex recon-structive challenge. The facial artery musculomucosal(FAMM) flap is a composite flap with features similar tothose of lip tissue. In this article, the anatomy, dissection,and clinical applications for the use of the FAMM flap inlip and vermilion reconstruction are discussed. A series of16 FAMM flaps in 13 patients is presented. Seven patientshad upper-lip reconstruction and six had lower-lip recon-struction. Superiorly based FAMM flaps were used in eightpatients, and eight inferiorly based flaps were performedin five patients. Three patients had bilateral, inferiorlybased flaps. In summary, the FAMM flap is a local flap thatcan be used for lip and vermilion reconstruction. Al-though not identical to the lip, it has many similar fea-tures, which make it an excellent option for lip recon-struction. (Plast. Reconstr. Surg. 105: 864, 2000.)

The lips are complex, laminated structuresconsisting of skin, subcutaneous tissue, mus-cles, submucosa, and mucosa. The vermilionspans the junction between the intraoral, moistmucosa and the keratinized, dry mucosa thatjoin the skin at the white roll. Further, the lipshave an exquisite contour, with a fullness inthe central part of the upper lip located imme-diately below the appropriately named Cupid’sbow. The upper lip protrudes anteriorly andoverlies the lower lip, which also has a charac-teristic contour. The upper and lower lips con-nect at the commissures, where the vermilionnarrows and is pulled inward and lateral to themodiolus, where the muscles responsible forsmiling blend with the muscles of oral compe-tence.

Clearly, when the lip is lost through injury ordisease, complete restoration is an unattain-able goal, and reconstruction is a challengethat relies mainly on sharing adjacent lip ele-

ments for reconstruction. Smaller, vertical seg-mental losses can readily be repaired by ad-vancing composite lower-lip elements.However, larger vertical segmental losses andhorizontal losses, especially involving the ver-milion, are more difficult to reconstruct.

The facial artery musculomucosal (FAMM)flap, which is taken from the lateral cheek, is acomposite flap. Although the tissue is not thesame as that in the lip, it has many features thatmake it a reasonable compromise for lip andvermilion reconstruction.

The FAMM flap is an axial flap based on thefacial artery as it courses through the cheeklateral to the buccinator muscle, but medial tomost of the other muscles of facial expression.It consists of the mucosa, submucosa, a smallamount of buccinator muscle, and a moredeeply lying facial artery and venous plexus. Itmay be used as a superiorly based flap, which isperfused in a retrograde manner by the angu-lar artery, a continuation of the facial artery; itmay also be based on the superior labialbranches and other anastomotic branchesfrom the infraorbital vessels (Fig. 1). The flapmay also be based inferiorly on the facial ves-sels as they enter the face at the anterior edgeof the masseter muscle (Fig. 2). We have usedthe FAMM flap to reconstruct a variety of struc-tures, including the palate, alveolus, nasal lin-ing, maxillary antrum, tonsilar fossa, soft pal-ate, and the floor of the mouth.1 Additionally,the FAMM flap has been used successfully forlip and vermilion reconstruction. Both the up-per and lower lip have been reconstructed us-ing both superiorly and inferiorly based flaps.We used this flap successfully in 13 patients for

From Brigham and Women’s Hospital. Received for publication July 1, 1999; revised September 15, 1999.

864

lip and vermilion reconstruction. The anatomyof the flap and our clinical experience with itwill be described in this article.

ANATOMY

The anatomy of this flap was previously de-scribed,1 and it is summarized here. The vascu-lar plexus of the cheek is located between thelaminae of the perioral muscles. The buccina-tor muscle forms the deepest layer of the peri-oral muscles, and it is considered part of asphincteric muscular system: the pharyngeal-buccal-orbicularis sphincter has multiple func-tions, such as whistling, sucking, and propel-ling food during mastication. The buccinatormuscle is covered medially by submucosa andmucosa and laterally by the external lamina ofthe muscles of facial expression, the masseter,ramus of the mandible, buccal fat pad, facialartery and vein, and buccopharyngeal fascia.

The blood supply to the cheek and its mus-culature comes from several sources. There is arich blood supply from the buccal artery, which

forms the basis for Bozola et al.’s2 axial flap,and from branches of the facial artery. Addi-tional contributions come from the posteriorsuperior alveolar artery and infraorbital artery.The rich venous drainage occurs by means of aplexus draining posteriorly to the pterygoidplexus and internal maxillary vein and anteri-orly to the facial vein.

The facial artery, a branch of the externalcarotid artery, enters the face by hookingaround the lower border of the mandible atthe anterior edge of the masseter muscle. Itfollows a tortuous course, passing upward andforward to a point lateral to the commissure ofthe mouth, where it lies deep to the risorius,zygomaticus major muscle, and superficial lam-ina of the orbicularis oris muscle. It lies super-ficial to the buccinator, the levator anguli orismuscle, and the lateral edge of the deep lam-ina of the orbicularis oris muscle, and it has avariable relationship to the levator labii supe-rioris muscle. At this point, it gives multipleperforators to the cheek and the superior la-

FIG. 1. Superiorly based FAMM flap design.

FIG. 2. Inferiorly based FAMM flap design.

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bial artery. It continues as the angular arteryand reaches the medial canthus. It also com-municates with the buccal and infraorbital ar-teries.

DISSECTION

We previously described the technique ofraising the FAMM flap1, but certain pointsmust be emphasized to ensure the survival ofthese flaps. For lip and vermilion reconstruc-tion, a long, narrow flap is generally required.For this reason, it is absolutely mandatory thatthe flap be extended over the facial artery sothat the artery remains axial throughout theentire length of the flap. A Doppler ultrasoundis used to mark the course of the facial artery.Then, for a superiorly based flap, the dissec-tion commences anteroinferiorly by cuttingthrough the mucosa, submucosa, and buccina-tor to expose the facial artery. The proceduredoes not proceed further until the facial arteryis definitely identified, ligated, and divided.The rest of the flap can then be incised, and

FIG. 3. A 21-year-old man with a painful, ulcerated arte-riovenous malformation of the lip and chin.

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FIG. 4. (Above, left) Defect after radical excision of arteriovenous malformation. (Above, right and below) We reconstructed thedefect with a radial forearm free flap folded over a palmaris longus tendon sling and bilateral, inferiorly based FAMM flaps placedover a deepithelialized segment of the free flap for vermilion reconstruction.

FIG. 5. Appearance of patient in Figure 4 1 year postoperatively (after minor revision ofvermilion and creation of supramental fold), with mouth open (left) and closed (right).

Vol. 105, No. 3 / RECONSTRUCTION WITH FAMM FLAP 867

the dissection continues from inferior to supe-rior, developing the flap containing the mu-cosa, submucosa, a strip of the underlying buc-cinator and, most importantly, the facial artery,which has fairly loose connections to the buc-cinator. In this manner, a long, axial flap mea-suring 7 to 8 cm can be raised safely. Becauseof the multiple layers included in the flap, theflap is about 8 to 10 mm in thickness. Typically,it is pink and viable, and it bleeds freely, evenat its distal end. Surprisingly, the flap does notappear congested, although no obvious large

vein runs with the facial artery, especially whenthe flap is superiorly based.

For flaps that are inferiorly based, a similarprocedure is followed. After the facial arteryhas been identified by Doppler ultrasound andmarked on the mucosa, the surgery com-mences anterosuperiorly to identify the arteryin the upper lip. Often, it may be easier to findthe artery 1 cm lateral to the oral commissureand dissect this out superiorly where the arteryis ligated and divided. The rest of the flap isthen incised and raised as an inferiorly basedaxial flap, again taking care to include theartery in the entire length of the flap. Whenraised inferiorly, the facial vein will becomeevident as it approaches the artery from a morelateral location in the cheek.

The FAMM flap is ideal for reconstructingthe inner, moist lip mucosa because it consistsof similar tissue, with the same color, texture,and moisture as a normal lip. When used forvermilion reconstruction, some drying-out of

FIG. 6. A 25-year-old woman who sustained a total lower-lip avulsing amputation after a human bite, showing defect(above) and amputated segment (center). (Below) Attemptedreplantation failed, with healing by secondary intention.

FIG. 7. Lip of patient in Figure 6 was reconstructed withbilateral advancement flaps and an inferiorly based FAMMflap from right side; the flaps are marked on the patient.

868 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2000

the mucosa will occur, but otherwise a goodcolor match can be obtained. Also, the bulk ofthe flap helps to restore lip fullness in cases oftotal lip loss.

CLINICAL APPLICATIONS

Since 1989, we have used 16 FAMM flaps in13 patients for lip and vermilion reconstruc-tion. The patients included 9 males and 4 fe-males, with ages ranging from 7 to 61 years.

Reconstruction of the upper lip was under-taken in seven patients and of the lower lip insix patients. In eight patients, the FAMM flapwas based superiorly. In one patient, a con-tralateral superior flap was used. Three pa-tients had bilateral inferior flaps, and two pa-tients had unilateral inferior flaps. A list ofpatients, indications, and procedures is givenin Table I.

To date, the most common diagnosis forwhich the FAMM flap was used for vermilionreconstruction was arteriovenous malforma-tion. Five patients with this diagnosis weretreated with the FAMM flap (seven flaps). Formost of these patients, the upper and lower lipand one or both commissures were involved. Inthese patients, extensive defects resulted afterradical excision of the malformation, whichthen required free flap reconstruction. TheFAMM flap was a useful adjunct for lip-vermilion reconstruction (Figs. 3 through 5).

In three patients, the lip defect was second-

FIG. 8. (Above) Interim result of patient in Figure 6 showsinadequate central lower-lip fullness because of the loss of thedistal tip of the right FAMM flap. (Center) Intraoperativephotograph taken 6 months later showing an additionalFAMM flap being raised from the left side. (Below) Final result3 months after all surgery was completed.

FIG. 9. A 32-year-old woman with a deficiency of the upperlip after the excision of a sarcoma involving the right upperlip and nose. The right heminasal deficit was reconstructedwith a full-thickness, ascending, helical free flap from the ear.

Vol. 105, No. 3 / RECONSTRUCTION WITH FAMM FLAP 869

ary to trauma; one defect was caused by a hu-man bite (Figs. 6 through 8), and another by amotor vehicle accident, with avulsion injury tothe upper lip and maxilla. One patient hadmultiple injuries because of a gunshot woundto the midface, and the FAMM flap was used asan adjunct to other reconstructive procedures.The gunshot-wound patient required four freeflaps before the FAMM flap for midfacial re-construction.

Two patients with a diagnosis of squamouscell carcinoma were treated. In one patient, acomposite nasolabial and FAMM flap was usedto reconstruct a full-thickness defect of theupper lip that extended into the base of thenose. One patient with a sarcoma of the upperlip and nasal region was treated with an ascend-ing helix flap for the nasal reconstruction anda FAMM flap for upper-lip reconstruction(Figs. 9 through 11). In one patient with hemi-facial microsomia, a deficiency in the vermilionportion of the upper lip was augmented with aFAMM flap (Figs. 12 and 13). A final patienthad osteoradionecrosis of the mandible, withscarring and depression of the lower lip. Thiswas debrided, and a FAMM flap was used toreconstruct the alveolus and adjacent lower lip.

DISCUSSION

Numerous techniques for lip and vermilionreconstruction have been described. Schulten,3in 1894, described the double-pedicle flap ofthe upper lip for the repair of a missing pro-labium segment in the lower lip. Lexer4 de-scribed a tongue flap in 1909. Other types oflocal advancement flaps were described byFriedlander,5 Spira and Stal,6 and Kolhe andLeonard.7 For superficial resurfacing of the

FIG. 10. A superiorly based FAMM flap was designed and raised from the left side and transposed into the upper lip of thepatient shown in Figure 9.

FIG. 11. Postoperative result of patient in Figure 9 at 6years.

870 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2000

vermilion, a cross-lip mucosal flap was de-scribed by Mazzola and Lupo8 in 1984 and thenagain by Standoli9 in 1994. This flap borrowslabial mucosa from the inner surface of one lipto resurface the vermilion of the other lip. Aninteresting technique described by Sakai et al.10

in 1988 and then again by Iwahira et al.11 in1998 involved the bilateral island vermilionflap or the sliding-door flap. Unipedicle andbipedicle cross-lip vermilion flaps were de-scribed by Kawamoto12 in 1979 and Lew et al.13

in 1987. In addition to local flaps, mucosal freegrafts have also been described by Ahuja,14 whoused labia minora grafts for vermilion recon-struction.

More recently, the buccinator myomucosalflap was introduced by Rayner and Arscott15 in1987. In this report, a sensate musculomucosalrandom flap from the buccal mucosa is used toresurface the vermilion. Bozola et al.,3 in 1989,

modified this flap slightly. They described anaxial buccinator musculomucosal flap basedon the buccal artery. Carstens et al.,16 in 1991,described a buccinator myomucosal flap basedon the facial artery. Most recently, in 1997,Ono et al.17 described a buccal musculomuco-sal flap that was also based on the facial artery.

Pribaz et al.,1 in 1992, described the FAMMflap. This flap differs slightly from the buccina-

FIG. 12. A 33-year-old man with hemifacial microsomiawho had a deficiency of the right upper-lip vermilion, whichgave the patient an unattractive “snarling” appearance. Hepreviously had unsuccessful attempts at reconstruction usingsynthetic GoreTex implants.

FIG. 13. (Above) The defect of the patient in Figure 12 wasrepaired with a superiorly based FAMM flap, which is markedon his left cheek mucosa. (Center) Intraoperative view oftransposing the FAMM flap into the upper lip. (Below) Result4 months postoperatively, showing adequate restoration of lipcontour.

Vol. 105, No. 3 / RECONSTRUCTION WITH FAMM FLAP 871

tor or buccal mucosal flaps in orientation andarterial supply. The FAMM flap consists of mu-cosa, submucosa, a small amount of buccinatormuscle, the deeper plane of the orbicularis orismuscle, and the facial artery and venousplexus. When used for lip reconstruction, it hasthe advantage of being completed in one stage,as compared with tongue flaps and cross-lipflaps, which require a secondary division andinset of the flap. Also, compared with otherbuccal flaps, the oblique orientation of theFAMM flap is more amenable for transpositionin lip reconstruction. Although very large buc-cal musculomucosal flaps of the entire cheekcould be safely raised because of the rich bloodsupply of the region, we have attempted tominimize donor-site morbidity by raising long,thin flaps. These axial flaps are, nonetheless,thick and robust, giving adequate bulk to thelip and allowing the donor defect to be easilyclosed. The oblique orientation of the flap al-lows resuturing of the muscular layer in a fa-vorable direction for minimal interferencewith facial expression. After the initial postop-erative swelling subsides, we have not noticedany significant weakness in the muscles of fa-cial expression.

Although a strip of buccinator muscle is har-vested with the flap, we have not studiedwhether this muscle remains functional aftertransfer. However, the muscular part of theflap is placed within the functioning orbicu-laris muscle. It appears to maintain its bulkand, thus, the contour of the lip.

We find the FAMM flap useful and safe tocorrect a wide variety of defects, both intraoraland nasal. It is especially useful for lip andvermilion reconstruction.

Julian J. Pribaz, M.D.Department of Plastic and Reconstructive SurgeryBrigham and Women’s Hospital75 Francis StreetBoston, Mass. 02115jjpribaz@bics.bwh.harvard.edu

REFERENCES

1. Pribaz, J., Stephens, W., Crespo, L., and Gifford, G. Anew intraoral flap: Facial artery musculomucosal(FAMM) flap. Plast. Reconstr. Surg. 90: 421, 1992.

2. Bozola, A. R., Gasques, J. A. L., Carriquiry, C. E., and deOliveira, M. C. The buccinator musculomucosalflap: Anatomic study and clinical application. Plast.Reconstr. Surg. 84: 250, 1989.

3. Schulten, M. V. En methodatt erstta en defekt af enalappen medelst en bryggformad lamba fran den anra.Fin. Lakaresallsk. Handl. 35: 859, 1894.

4. Lexer, E. Wangenplastik. Dtsch. Z. Chir. 100: 206, 1909.5. Friedlander, A. H. Modified lip stripping with recon-

struction of a new vermilion border. N. Y. State Dent.J. 42: 27, 1976.

6. Spira, M., and Stal, S. V-Y advancement of a subcuta-neous pedicle in vermilion lip reconstruction. Plast.Reconstr. Surg. 72: 562, 1983.

7. Kolhe, P. S., and Leonard, A. G. Reconstruction of thevermilion after ‘lip-shave.’ Br. J. Plast. Surg. 41: 68,1988.

8. Mazzola, R. F., and Lupo, G. Evolving concepts in lipreconstruction. Clin. Plast. Surg. 11: 583, 1984.

9. Standoli, L. Cross lip flap in vermilion reconstruction.Ann. Plast. Surg. 32: 214, 1994.

10. Sakai, S., Soeda, S., and Terayama, I. Bilateral islandvermilion flaps for vermilion border reconstruction.Ann. Plast. Surg. 20: 459, 1988.

11. Iwahira, Y., Yataka, M., and Maruyama, Y. The slidingdoor flap for repair of vermilion defects. Ann. Plast.Surg. 41: 300, 1998.

12. Kawamoto, H. K. Correction of major defects of thevermilion with a cross-lip vermilion flap. Plast. Reconstr.Surg. 64: 325, 1979.

13. Lew, D., Clark, R., Jimenez, F., and Deitch, E. A. Thebipedicled lip flap for reconstruction of the vermilionborder in the patient with a severe perioral burn. OralSurg. Oral Med. Oral Pathol. 63: 526, 1987.

14. Ahuja, R. B. Vermilion reconstruction with labia mi-nora graft. Plast. Reconstr. Surg. 92: 1418, 1993.

15. Rayner, C. R., and Arscott, G. D. A new method of re-surfacing the lip. Br. J. Plast. Surg. 40: 454, 1987.

16. Carstens, M. H., Stofman, G. M., Hurwitz, D. J., Futrell,J. W., Patterson, G. T., and Sotereanos, G. C. Thebuccinator myomucosal island pedicle flap: Anatomicstudy and case report. Plast. Reconstr. Surg. 88: 39, 1991.

17. Ono, I., Gunji, H., Tateshita, T., and Sanbe, N. Recon-struction of defects of the entire vermilion with abuccal musculomucosal flap following resection ofmalignant tumors of the lower lip. Plast. Reconstr. Surg.100: 422, 1997.

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