Special Topic

Buccal Mucosal Flaps: A ReviewErdem Tezel, M.D.Istanbul, Turkey

The defects of mucosal surfaces of the face,either congenital, traumatic, or postoperative,have been prominent subjects of plastic sur-gery. Local skin flaps and free flaps have beenused to repair these defects. Because the face isthe most vascularized portion of the body, skinflaps in this area have a great chance for via-bility. Buccal mucosa also shares the same fea-ture of vascularity and thus has the capability ofamazingly fast healing. Taking into consider-ation these features, and the idea of using themost similar tissue for reconstruction, it is easyto understand why plastic surgeons have de-scribed many oral mucosal flaps. The purposeof this article is to collate, summarize, andcritique the information available on the mu-cosal flaps. I reviewed the buccal mucosal flapsaccording to their sites of use.

LIP AND VERMILION RECONSTRUCTION

Lips are a flexible, mobile structure of theface and perform many functions: prehensionof solids, prevention of drooling and loss offood during mastication, formation of labialsounds, accomplishment of a sphincteric ac-tion that is particularly evident in the newborn,and expression of emotions.1 The lips areformed by a muscular layer, covered externallyby skin and covered internally by “wet” mucousmembrane and submucosa. The vermilionconstitutes the transitional zone between wetmucosa inside and skin outside.

Images of lips are drawn and sculpted byartists. They are praised in poetry and serve assubjects of songs. Lips are decorated, embel-lished, and painted with variations in style fromculture to culture. Despite any changes per-formed, it is undeniable that lips, in their nat-ural, unaltered state, are truly objects of fasci-nation and beauty.2 Of course, vermilion is one

of the most important parts of the lips, and itsreconstruction is an inevitable goal. It is a ma-jor challenge for plastic surgeons, especially inwide defects. Vermilion reconstruction is acomplementary operation of lip reconstruc-tion. A defect or irregularity of the vermilionspoils the appearance of an otherwise excel-lently repaired lip.

Various methods have been employed forsuch wide defects. Schulten3 described a bi-pedicled flap of the upper lip for reconstruc-tion of missing vermilion of the lower lip. AfterSchulten, several vermilion flaps were de-scribed. The advancement flaps of the neigh-boring vermilion must be taken into consider-ation first in small defects.4–7 Vermilion flapsfrom the opposite lip may be the other alter-native. Despite very good results reported,8–10

in general, two major shortcomings of theseflaps must be mentioned: the operations are intwo stages and cause deformity on the oppositevermilion.

The tongue flap was first used for vermilionrepair by Lexer11 in 1909. The rich vasculariza-tion of the tongue makes use of this flap reli-able. However, the operation is a two-stage pro-cedure, and the patient is not comfortable withhis or her tongue being attached to the lipwhile awaiting division. Moreover, these resultsare not always satisfactory from a cosmeticpoint of view.

Vestibular mucosa can be advanced in a su-peroanterior direction to cover the vermiliondefect, but the results are not satisfactory. Ver-milion becomes thin and the vestibule be-comes shallow. This can cause food spillageduring eating. The tension-free lip margin ispulled inward and hairs on the lower lip skincause irritation.12 To overcome these problemsof the vestibular advancement flap, Wilson and

From the Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine. Received for publication February 20,2001; revised June 5, 2001.

735

Walker13 made a releasing incision at the gin-givobuccal sulcus. Thus, it became a bipediclemucosal flap.

Kolhe and Leonard12 applied the V-Y ad-vancement procedure to this releasing inci-sion. However, all these were not enough toovercome the previously mentioned problems,and that is why further flap descriptions byseveral authors were continued. Pelly andTan14 used a musculomucosal flap from thebuccal aspect of the upper lip for resurfacingthe lower lip vermilion defect. This flap was 1� 3 cm in size and based on the modiolus.

The amount of excess tissue in the upper liplimits the application of upper lip flaps (eithersingle pedicled or bipedicled) for large de-fects. Rayner and Arscott15 resurfaced the lowerlip vermilion with paired musculomucosal flapsfrom the cheeks. The flaps were based at theangle of the mouth, and distal ends were justbelow the parotid duct. The width of the flapswas 1 cm each. Two flaps can cover the wholevermilion by joining in the midline (Fig. 1).The only problem mentioned by the authorswas central depression where two flaps werejoined and sutured to each other.

The first island mucosal flap was describedby Carstens et al.16 (Fig. 2). They showed intheir anatomical study that the musculomuco-sal flap, based on the facial artery, can be har-vested as large as 7 � 5 cm. It requires metic-ulous dissection with loupe magnification andmay necessitate external nasolabial incision.They reported two lip reconstructions and sev-eral oral mucosal defect closures.

One year later, another type of musculomu-cosal flap with a facial artery pedicle was de-scribed17 (Fig. 3). This flap is planned on thecourse of facial artery with the help of Dopplerultrasound. Mucosa, submucosa, and a smallamount of buccinator muscle are harvestedwith the facial artery as an axial flap. The pivotpoint of this flap is on the retromolar trigone,

and the flap extends to the upper gingivobuc-cal sulcus. During surgery, care should betaken to ensure that the flap remains axial,with the facial artery running along its entirelength, and that there are no twists or con-straints on the pedicle. Despite good resultspresented recently,18 this is not easy and re-quires very fine surgical technique and skill.

Ono et al.19 described a musculomucosalflap pedicled at the angle of the mouth. Theyincluded the buccinator muscle for the entirelength of the flap. The maximum size of theflap was 1.5 � 5 cm. After resection of thetumor on the lower lip, they made a supple-mentary wedge excision and thus diminished

FIG. 1. Rayner and Arscott’s flap to cover vermilion. Twoflaps join at the midline and lead to the central depression.

FIG. 2. Island mucosal flap based on the facial artery.

FIG. 3. Musculomucosal flap planned on the course of thefacial artery.

736 PLASTIC AND RECONSTRUCTIVE SURGERY, February 2002

the length of the vermilion defect. Then theytransposed the musculomucosal flap to the ver-milion defect.

Tezel et al.20 described a “commissure-basedbuccal mucosal flap,” which has a randompedicle (Fig. 4). This flap is based at the oralcommissure and lies just below the parotidduct opening and extends to the retromolartrigone. A commissure-based buccal mucosalflap consists of mucosa, submucosa, and mus-cle only under the proximal 1.5 to 2 cm of theflap. Being as large as 3 � 6 cm, the buccalmucosal flap based on the commissure caneasily cover an entire vermilion defect by plac-ing the flap from one commissure to the other(Fig. 5). Bilateral commissure-based buccalmucosal flaps were used for lip reconstructionwith one of the flaps resurfacing the vermiliondefect and the other one covering the innerside of the lip. Because no extra effort is nec-essary to identify the artery or nerve, it is easy toharvest the flap, and donor morbidity isminimal.

The most important structure when usingcheek mucosa as a flap is the orifice of theparotid duct. Care must be taken to spare it.The two important problems when using oralmucosa outside of the mouth are dryness andedema. Dryness and keratotic changes of themucosal flap are thought to stem from histo-logic differences between oral mucosa and thevermilion. It may be a cause to increase theedema. Use of moisturizing pomades regularlyfor a few months helps reduce both problems.

Donor defects of the flaps in cheek mucosa upto 3 cm wide can be closed primarily. Thewider donor-site defects can be closed withgrafts or be left for secondary healing. Primaryclosure is always preferable. Because most ofthe patients who suffer from tumors of thelower lip are elderly, one-stage operations aresuperior to two-stage procedures, such as cross-lip flaps and tongue flaps.

Several authors described numerous beauti-ful results with different mucosal flaps; some ofthem are mentioned above. In deciding on theproper flap, the size of the defect, the age ofthe patient, the time of the operation, theequipment, and the skill and experience of thesurgeon must be weighed.

GINGIVOBUCCAL SULCUS RECONSTRUCTION

Traumatic or postoperative obstruction ofthe gingivobuccal sulcus restrains lip mobility,causes inward displacement of lip, and limitsthe use of tooth prostheses. Repair of the gin-givobuccal sulcus is one of the most importantparts of lip reconstruction. Using skin grafts forsulcus is not only cumbersome, the results arealso far from satisfactory. Pressure must be puton the grafts for at least 5 days by special moldsthat often cause maceration, odor, and discom-fort for the patient. Even if the graft takes well,secondary contraction of the graft is a nearlyinevitable outcome. Of course, buccal mucosalflaps are superior to grafts for reconstructingthe moist mucosa of the sulcus because it con-sists of similar tissue, with the same texture,color, and moisture. One good alternative isthe island mucosal flap described by Carstenset al.16 The size of the flap provides sufficientmucosal tissue to cover the whole sulcus. Theother options are the musculomucosal flapbased on the facial artery and the buccal mus-culomucosal flap of Ono et al.17–19 The com-missure-based buccal mucosal flap described

FIG. 4. Commissure-based buccal mucosal flap. This is a ran-dom-pedicled flap based at the oral commissure.

FIG. 5. A commissure-based buccal mucosal flap can coveran entire vermilion defect.

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by Tezel et al.20 is another option (Fig. 4). Withbilateral elevation of the commissure-basedbuccal mucosal flap, buccal and gingival sur-faces of the sulcus or buccal surface of thesulcus and vermilion can be corrected simulta-neously, as shown in their article (Fig. 6). Thisprocedure easily allows us to create the depthof the sulcus and can be applied to the otherpreviously mentioned flaps by elevating thembilaterally. I believe that reconstruction of the

gingivobuccal sulcus with mucosal flaps pro-vides a far superior result in lip reconstructionsfor both functional and aesthetic aspects.

PALATAL RECONSTRUCTION

The primary aim of the cleft palate opera-tion is not only to close the cleft but also toproduce a long and mobile soft palate, thusachieving physiologic velopharyngeal function.This is necessary for normal speech, naturalbreathing, and deglutition, and it also preventsmiddle ear inflammation.

The pushback operation is an effective pro-cedure for velopharyngeal closure, but it doesnot adequately lengthen the nasal layer. Manymethods of palatal repair have been describedto permit lengthening of the nasal layer after apushback procedure. The use of buccal muco-sal flaps for lengthening the nasal mucosa wasfirst described by Mukherji.21 He used bilateralbuccal mucosal flaps based near the anteriorpillar of the fauces for both nasal and oral layerclosure, either separately or in combination. Inhis article, he summarized the advantages ofthe buccal mucosal flaps as an increase in thelength of the soft palate of at least 1.5 cm,prevention of the abnormal anatomy of pha-ryngeal flap operation in a fair number of chil-dren with cleft palate, and a decrease in theincidences of perforation at the junction of thesoft and hard palates.

Jackson22 utilized local random buccal flapsfor closure of secondary palatal fistulas, andconcluded that the buccal mucosal flap is in-valuable with its extreme flexibility to fit intodefects of various sizes and shapes. Ganguli23

detached the soft palate from the hard palateand restored the continuity of the palate bybuccal mucosal flaps.

In 1975, Kaplan24 proposed the use of a uni-lateral buccal mucosal flap to be turned in fornasal lining after dividing the nasal mucosa(Fig. 7). Two different flap designs accordingto the base of the flap, retromolar trigone andposterior alveolar buccal sulcus, were de-scribed. Kaplan’s aim was to achieve normalvelopharyngeal function without causing max-illary-alveolar growth deformities. Maeda etal.25 also mentioned the importance of maxil-lary growth impairment and used the bilateralbuccal musculomucosal flap to minimize surgi-cal trauma to the hard palate (Fig. 8).

Jackson et al.26 described the technique ofpalatal closure that consisted of a transversedivision of the nasal layer, insertion of a buccal

FIG. 6. (Above) Two commissure-based buccal mucosalflaps can be used for gingivobuccal sulcus reconstruction: oneof the flaps is used to resurface the gingiva and the contralat-eral flap is used to cover the inner surface of the lip. (Below)Lateral section of sulcus reconstruction by two commissure-based buccal mucosal flaps. Note that the suture between thetwo flaps also passes through the periosteum of the mandibleto create the depth of the sulcus.

738 PLASTIC AND RECONSTRUCTIVE SURGERY, February 2002

flap for lengthening, and closure of the oralmucosal layer with Veau flaps without dissec-tion behind the tuberosities and with almosttotal closure of the lateral donor sites on thepalatal shelves. It is stated that with this tech-nique there was minimal scarring in the retro-tuberosity area, which is more important forfacial growth than the palatal shelves.

The fate of buccal mucosal flaps in primarypalatal repair was reported by Freedlander andJackson.27 They suggested placing the pedicleof the mucosal flap as far posteriorly as possi-ble, acknowledging that the eruption of themolar might be impeded. In this case, theysuggested severing the flap pedicle to expose

the molars. They concluded that buccal muco-sal flaps must be reserved for wide clefts.

The first axial buccal musculomucosal flapbased on the buccal artery was described byBozola et al.28 They used a Y-shaped buccalmucosal flap with the buccinator muscle tocover the raw surface of the palate. It is pre-sented in their article that the buccinator mus-culomucosal flap was not only used for widecleft palates but also for the treatment of mu-cosal defects after tumor resection, osteomyeli-tis of the mandible, and closure of the palatalfistulas.

Nakakita et al.29 modified their technique byusing the buccal mucosal flap for oral lininginstead of using it for back shift of nasal mu-cosa. They stated that leaving a raw surface,especially on the soft palate, causes contrac-

FIG. 7. (Above) Kaplan’s buccal mucosal flap for palatereconstruction. (Below) The buccal mucosal flap is turned infor nasal lining, and the donor site is closed primarily.

FIG. 8. (Above) Turnover of a buccal musculomucosal flapfrom one site (on the right side in this drawing) and itstransplantation onto the nasal mucosal defect. On the leftside, the bilobular musculomucosal flap is planned for oralmucosal covering. (Below) A bilobular musculomucosal flapis rotated to the oral mucosal defect. Thus, one of the mucosalflaps is turned over for the nasal surface covering and theother one (bilobate flap) is rotated to cover the oral mucosaldefect.

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tion. Thus, to minimize the amount of rawsurface left on the soft palate, and on the hardpalate, two musculomucosal flaps were used fororal covering.

Ohishi et al.30 used bilateral buccal mucosalflaps to cover the donor site of palatal flaps.Their operation was principally based on vonLangenbeck’s method, but the palatal flapswere dissected at the submucosal level to min-imize the trauma to the maxillary bone.

Carstens et al.16 described an island-pedicledmusculomucosal flap. They stated that theprincipal supply to the buccinator muscle isthe facial artery instead of the buccal artery asclaimed by Bozola et al.28 According to theiranatomic study, a 7 � 5-cm flap can be har-vested as a musculomucosal island flap. Thisflap was used for lip reconstruction, palatalfistula repair, alveolar augmentation, andfloor-of-mouth reconstruction. Another facialartery–pedicled flap was described as the facialartery musculomucosal flap.17 This flap wasplanned on the course of the facial artery withDoppler ultrasound. It has two pivot point al-ternatives: superiorly at the gingivobuccal sul-cus and inferiorly at the retromolar trigone.They used this flap for reconstruction of thealveolus, nasal septum, lips, floor of mouth,hard palate, and soft palate.

The commissure-based buccal mucosal flapwas used to cover the maxillary defects aftertumor resection. Bilateral use of this flap cancover a defect as large as 6 � 6 cm.20

Recently, the detailed anatomic study ofZhao et al.31 has shown that there is very richvascularity in the buccinator muscular mucosalsystem. They developed two patterns of bucci-nator musculomucosal island flaps. One is aposteriorly based flap supplied by the buccalartery, and the other is a superiorly based flapsupplied by the distal portion of the facial ar-tery. They reported successful clinical results ofpalatal reconstruction.

NASAL RECONSTRUCTION

Skin grafts, mucosa grafts, composite grafts,or skin flaps have been used for nasal lining.Survival of the intranasal grafts is often unpre-dictable and graft contraction is not uncom-mon. Skin flaps usually obstruct the airway withtheir bulkiness. The use of buccal mucosalflaps for nasal reconstruction was described byFiliberti,32 who gives full credit to the origina-tor of the technique, O. Suarez.

Tipton33 described a mucosal flap that was1.5 cm wide and 4 to 5 cm in length at theinner aspect of the upper lip (Fig. 9). He usedthis flap for septal perforations. The flap waspassed through a tunnel between the uppersulcus and floor of the nasal cavity. Similarflaps for nasal reconstruction were reported bySoutar et al.34 and Rayner.35

Successful results of axial or island-pedicledmusculomucosal flaps have been reportedrecently.17,31

ORBITAL RECONSTRUCTION

Orbito-oral drainage with buccal mucosalflaps was described by Rayner.35 He used a 1 �3-cm mucosal flap based near the frenulum ofthe upper lip. The flap passed through a tun-nel from the maxilla up to the orbit. Most ofthe mucosal flaps described in this article areuseful for this purpose. Island pedicle flapsespecially have potential for use in socket or lidreconstructions. Successful results of lower lidreconstruction with the island musculomuco-sal flap are reported by Zhao et al.31

Buccal mucosal flaps have several advan-tages, and they are extremely flexible and avail-able in adequate amounts. Several pedicle al-ternatives, either random or axial, increase thechoices of buccal mucosal flaps according todefects. Flaps easily fit into defects of varioussizes and shapes because of their flexibility,and the flaps blend well with surrounding mu-cosa. In most techniques, the donor sites areclosed primarily, without causing deformity or

FIG. 9. Tipton’s mucosal flap at the inner aspect of theupper lip.

740 PLASTIC AND RECONSTRUCTIVE SURGERY, February 2002

visible scars. However, in large flaps donor sitesneed to be grafted. Otherwise, the raw surfaceswill be left to heal by secondary intention andmay lead to cheek scarring that can limitmouth opening.

Erdem Tezel, M.D.Cezmi Or Sok 8/1 Emek Ap81030 CiftehavuzlarIstanbul, Turkey

ACKNOWLEDGMENTS

I would like to thank Drs. Ian T. Jackson and MichaelSchenden for their valuable help in preparation of thisarticle.

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2. Romm, S. On the beauty of lips. Clin. Plast. Surg. 11: 571,1984.

3. Schulten, M. W. En method att erstta en defekt af enalappen medelst en bryggformad lamba fran den an-dra. Finska Lak-Sallsk-Hande. 35: 859, 1894.

4. Goldstein, M. H. A tissue-expanding vermilion myocu-taneous flap for lip repair. Plast. Reconstr. Surg. 73: 768,1984.

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8. Kawamoto, H. K., Jr. Correction of major defects of thevermilion with a cross-lip vermilion flap. Plast. Reconstr.Surg. 64: 315, 1979.

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

18. Pribaz, J. J., Meara, J. G., Wright, S., Smith, J. D., Stephens,W., and Breuing, K. H. Lip and vermilion recon-struction with the facial artery musculomucosal flap.Plast. Reconstr. Surg. 105: 864, 2000.

19. 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.

20. Tezel, E., Numanoglu, A., Celebiler, O., and Bayramicli,M. Commissure-based buccal mucosal flap. Plast. Re-constr. Surg. 101: 1223, 1998.

21. Mukherji, M. M. Cheek flap for short palates. Cleft PalateJ. 6: 415, 1969.

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23. Ganguli, A. C. Surgical management of the short pal-ate. Trans. Int. Congress Plast. Reconstr. Surg. Butterworth1971: 247.

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27. Freedlander, E., and Jackson, I. T. The fate of buccalmucosal flaps in primary palatal repair. Cleft Palate J.26: 110, 1989.

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29. Nakakita, N., Maeda, K., Ojimi, H., Utsugi, R., andMaekawa, J. The modified buccal musculomucosalflap method for cleft palate surgery. Plast. Reconstr.Surg. 88: 421, 1991.

30. Ohishi, M., Miyanoshita, Y., Suzuki, A., and Goto, K. Arevisited method of conservative palatoplasty. J. Crani-omaxillofac. Surg. 20: 198, 1992.

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32. Filiberti, A. T. Plastic closure of septal perforation. Ann.Chir. Otorhinolaryngol. (Cordoba) 96: 1, 1965.

33. Tipton, J. B. Closure of large septal perforations withlabial-buccal flap. Plast. Reconstr. Surg. 46: 514, 1970.

34. Soutar, D. S., Elliot, D., and Rao, G. S. S. Buccal mucosalflaps in nasal reconstruction. Br. J. Plast. Surg. 43: 612,1990.

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