ORIGINAL ARTICLE

Role of Facial Artery Musculomucosal Flap in Large and RecurrentPalatal Fistulae

Rahul Shetty, M.B.B.S., M.S., M.Ch., Shashank Lamba, M.B.B.S., M.S., M.Ch., Ashish Kumar Gupta, M.B.B.S., M.S., M.Ch.

Objective: Palatal fistulas are not uncommon after palatoplasty. Although there are currentlymany techniques that can be used to close large palatal fistulae, most of these procedures areusually cumbersome and mostly unreliable with high recurrence rates. The facial arterymusculomucosal (FAMM) flap was described to circumvent these problems. The purpose of thisstudy was to review our experience with the FAMM flap to reconstruct palatal fistulas, most ofthem being recurrent.

Materials and Methods: A retrospective analysis was done of 11 FAMM flaps performedbetween January 2007 and March 2012.

Results: There were no major complications. Venous congestion was seen in two cases. Twoflaps developed terminal marginal necrosis. One patient had suture line dehiscence. There wereno recurrences of the fistula after repair. All patients had a satisfactory closure of the fistula.

Conclusion: FAMM flap is a reliable and versatile flap that provides like with the like tissueand is a good option for closure of recurrent wide palatal fistulae.

KEY WORDS: cleft palate surgery complications, facial artery musculomucosal flap (FAMM flap),palatal fistulas

Palatal fistulas are common and complicated sequelae of

cleft palate surgery. About 0% to 45% of all palatal cleft

surgeries result in a palatal fistula (Musgrave and Bremner,

1960; Cohen et al., 1991; Losken et al., 2011). The problem

is compounded when 25% to 34% of palatal fistula

surgeries result in recurrence (Cohen et al., 1991; Emory et

al., 1997; Muzaffar et al., 2001). Closure of palatal fistula is

difficult because of lack of surrounding soft tissue in the

palate and excessive scarring due to previous surgeries.

Provision of fresh, unscarred, and well-vascularized tissue

in the form of a regional flap can be invaluable in treating

these fistulas. The main goals of reconstruction of these

fistulas are to restore internal oral lining, preserve or

improve the function of residual structures, replace mucosa

with tissues having similar features, and have the best

esthetic result possible.

A variety of surgical techniques have been suggested

for the closure of the fistulas depending on their size and

location. Based on their size, fistulas were classified as

small (,2 mm), medium (2 to 5 mm) and large (.5 mm;

Cohen et al, 1991). For small palatal fistulas, a local

turnover flap is usually used. In cases of mid palatal

fistulas with adequate surrounding soft tissue, a redo

palatoplasty is a good option. For large fistulas, various

flaps have been described including cheek/buccal

mucosa flap (Mukherji, 1969), tongue flap (Guerrero-

Santos and Altamirano, 1968), facial artery musculo-

mucosal (FAMM) flap (Pribaz et al., 1992), and free

tissue transfer (Chen et al., 1992).

The FAMM flap was first described by Pribaz et al. in

1992, and because of its versatility and reliability, it was

seen as a possible solution to this difficult problem.

Some studies have also assessed its use in oral cavity

reconstructions, with most of them being after oral

malignancy excisions (Joshi et al., 2005; Bianchi et al.,

2009). The vascular basis of the facial artery flap has

already been well described in the literature (Musgrave

and Bremner, 1960; Pribaz et al., 1992; Dupoirieux et

al., 1999; Lahiri and Richard, 2007). The FAMM flap

contains buccal mucosa, submucosa, part of the

buccinators, and facial artery with its venous plexus.

It is reliable both as a superiorly based or inferiorly

based flap. When fistulas are in the anterior half of the

hard palate, superiorly based flaps are used. For fistulas

in the rest of the hard palate, inferiorly based flaps are

used (Lahiri and Richard, 2007).

We present our experience with FAMM flap for closure

of palatal fistulas. The aim was to assess the reliability and

associated complications of palatal fistula closure with the

FAMM flap.

Dr. Rahul Shetty is Senior Postgraduate Registrar, Dr.Shashank Lamba, is Assistant Professor, and Dr. Ashish KumarGupta is Professor and Head, Department of Plastic andReconstructive Surgery, Christian Medical College, Vellore, India.

Submitted May 2012; Accepted November 2012.Address correspondence to: Dr. Rahul Shetty, Department of

Plastic and Reconstructive Surgery, Christian Medical College,Vellore-632004, TN, India. E-mail rahulplastic@hotmail.com.

DOI: 10.1597/12-115

730

The Cleft Palate-Craniofacial Journal 50(6) pp. 730–733 November 2013� Copyright 2013 American Cleft Palate-Craniofacial Association

MATERIALS AND METHODS

We performed a retrospective analysis of FAMM flapsdone between January 2007 and March 2012. Medicalrecords of these patients were checked and data reviewedfor demographic profile, complaints, etiology of fistula, sizeof fistula, treatment, and complications. All flaps were doneby the same surgeon. Fully informed consents wereobtained prior to surgery and principles outlined in theDeclaration of Helsinki were followed.

Operative Technique

The procedure was performed under general anes-thesia. The nasal lining was repaired with turnoverflaps (Fig. 1). These flaps were designed to be largerthan the defect. The course of the facial artery wasmarked with a handheld Doppler. The parotid ductwas identified and marked. This prevents accidentalinjury to the duct. The flap was marked medial to theduct, which limits the posterior extent of the flap. Theanterior flap marking starts 1 cm posterior to the oralcommissure. The size of the flap was tailored propor-tionally to the size of the defect. The width of the flapwas kept to about 2 to 2.5 cm to avoid tension in theclosure of the donor site. An initial incision was made 1cm posterior to the oral commissure to identify thesuperior labial artery, which could be traced back tothe facial artery. The incision was deepened throughthe buccal mucosa, submucosa, and underlying mus-cles (buccinators and a small portion of the orbicularisoris near the commissure) into the layer of buccal fat.The flap was dissected in a retrograde or antegrademanner depending on the site of fistula, maintainingthe vessels in a central position in the flap (Fig. 2). Theflap was then swung over a pivot at the base of thepedicle and used to cover the defect. Care was taken to

avoid kinking or twisting the pedicle. In the case ofsuperior-based flaps, the pedicle was guided into theoral cavity either by bridging over the dentition orthrough a gap in the dentition if present. In the case ofinferiorly based flaps, the pedicle was positioned tocover the defect through the retromolar fossa.Once completely raised, the flap was inset and the

donor site was closed primarily with 4-0 polyglactin(Vicryl) interrupted sutures.Bite block was used postoperatively in all cases.

Patients were put on a soft diet for 1 week anddischarged after 48 to 72 hours. The results wereassessed for anatomical continuity during follow-upoffice visits (Figs. 3a and 3b).

RESULTS

A total of 11 patients were treated with the FAMMflap. The average age of the patients was 12 years. Therewere seven boys (63.63%) and four girls (36.36%). Nine(81.1%) of the fistulas were due to cleft palate surgery,one was due to dental cyst excision, and one was due totumor excision (i.e., juvenile angiofibroma). Nine(81.8%) of the patients had recurrent fistulas. Thefistulae were between 1 and 2 cm in size. Nine of thepatients complained of discomfort due to nasalregurgitation. Three (27.27%) flaps were inferiorlybased and eight (72.72%) superiorly. Two flapsdeveloped venous congestion (,4 to 6 hours), whichresolved on its own without any active intervention(,48 hours). Two flaps (18.8%) developed terminalmarginal necrosis. One flap (9.9%) developed sutureline dehiscence. All flaps were divided and inset at 3weeks. All our patients were followed up for a periodranging from 6 months to 2 years, with a mean follow-up of 8 months. Satisfactory closure of the fistula wasobtained in all patients (Table 1).

FIGURE 1 a: Palatal fistula with nasal turnover flap marked on

adjacent normal tissue. Raised FAMM flap seen near oral commissure.

FIGURE 2 Facial artery identified in the flap and maintained in central

position throughout length of flap.

Shetty et al., ROLE OF FAMM FLAP IN PALATAL FISTULAE 731

DISCUSSION

Closure of a hard palatal fistula is a challenging problem.

In the literature, recurrence after palatal fistula closure has

been reported to be 25% to 33% (Reid, 1962; Schultz, 1986;

Cohen et al., 1991). Risk of fistula increases with every

failure. Therefore, all attempts should be made for

successful palate repair during the first surgery. It is

desirable to repair palatal fistulas in two well-vascularized

layers (separate nasal and oral) without tension (Mathes et

al., 2005). Attempts at repair with local palatal tissue can be

difficult because of the scarcity of tissue and residual

scarring from previous attempts at closure. Different

surgical techniques are described for closure of large palatal

fistulas such as buccal flap, buccal padflap, tongue flap, and

FAMM flap.

FAMM flap is considered a better option over other

musculomucosal flaps by its axial pattern blood supply

and minimal donor site morbidity (Pribaz et al., 1992).

However, flap elevation can be technically challenging.

The tongue flap described by Guerrero-Santos and

Altamirano (1966) has been considered for recurrent

defects. It provides a large source of tissue for closure of

problematic palatal fistulas. A second stage surgery is

required for flap division usually after 3 weeks. In

addition, the texture, color, and consistency of the

tongue flap makes it less than ideal for palatal repair

(Mathes et al., 2005). The buccal mucosal flap is a

random-pattern flap and hence unreliable. It also

cannot be used for anterior fistulas (Freedlander,

1989), and the tissue provided by this flap is limited

for large fistulas. The buccal fat pad is another useful

option in managing mid and posterior palatal fistulae.

Ashtiani et al. (2011) reported managing 28 of the 29

patients with palatal fistula with the buccal fat pad flap.

As this flap is useful mainly for junctional fistulae, it is

less versatile as compared with the FAMM flap.

Microvascular free-tissue transfer such as radial fore-

arm flap (Chen et al., 1992) has been used to achieve

closure of particularly large palatal defects resistant to

other methods. However, use of free flaps requires

competence in microsurgery, long operative time, and

prolonged hospitalization. It may also lead to donor site

morbidity and esthetically unsatisfactory results (Bian-

chi et al., 2009).

FIGURE 3 a: Preoperative picture of patient with a wide anterior fistula. b: After Reconstruction with a FAMM flap.

TABLE 1 Patient Details

Sl No. Age/Sex Indication* Location/size Type of Flap Postoperative Complications Final Outcome

1 4 years/F UCLP Anterior fistula, 1.5 cm2 Inferiorly based Nil Completely healed2 16 years/M BCLP Anterior fistula, 1 cm2 Superiorly based Venous congestion Completely healed3 39 years/M Dental cyst excision Anterior fistula, 1.2 cm2 Superiorly based Distal third necrosis Completely healed4 16 years/M BCLP Midpalatal fistula, 2 cm2 Inferiorly based Suture line dehiscence Completely healed5 23 years/F CP Anterior fistula, 1.8 cm2 Inferiorly based Nil Completely healed6 12 years/F BCLP Posterior fistula, 1.2 cm2 Superiorly based Nil Completely healed7 14 years/M CP (Group 3) anterior fistula, 1 cm2 Superiorly based Nil Completely healed8 7 years/F CP Posterior fistula, 1.2 cm2 Superiorly based Nil Completely healed9 11 years/M BCLP Posterior fistula, 2 cm2 Superiorly based Distal third necrosis Completely healed

10 16 years/M UCLP Anterior fistula, 1 cm2 Superiorly based Venous congestion Completely healed11 15 years/M Angiofibroma excision Posterior fistula, 1.9 cm2 Superiorly based Nil Completely healed

* UCLP ¼ unilateral cleft and palate; BCLP¼ bilateral cleft and palate; CP ¼ cleft of palate.

732 Cleft Palate-Craniofacial Journal, November 2013, Vol. 50 No. 6

None of the 11 patients in our study had any majorcomplications. Two of the flaps developed venouscongestion in the immediate postoperative period,which resolved without any active intervention. Thisvenous congestion is a common occurrence in FAMMflaps, as has been mentioned in the literature. Dupoir-ieux et al. (1999) mentioned that the vein follows theartery at a variable distance of about 15 mm in the upperpart of the flap at the level the of ala nasi and at a lesserdistance (approximately 4 mm) near the mandible.Some studies (Janfaza et al., 2001; Bianchi et al., 2009)have indicated that venous drainage is by a plexus ofveins and not a single vein. Keeping these factors inmind, we keep a broad base for all our flaps, whichensures adequate venous drainage. Two patients had amarginal flap necrosis, which we attributed to failure tocentralize the artery in the flap over the entire course.These flaps healed by mucosalization and did not needany further intervention. One patient had a suture linedehiscence, probably due to the thinned mucosa towhich the flap was sutured. The flap was subsequentlyadvanced and resutured, following which the fistulahealed uneventfully.The base of the flap in our study was kept 2 to 2.5 cm

wide to ensure adequate venous drainage and flapsuccess. We use the FAMM flap for the oral lining afterthe nasal lining is closed with a local turnover flap. Thisstep is of paramount importance in preventing recurrentfistulae. These turnover flaps are designed to be largerthan the defect because the scarred palatal mucosa isinelastic and covers less area than it appears when theflap is designed. Preoperative identification of theparotid duct is important to prevent its inadvertentinjury during flap elevation. Initial dissection of thesuperior labial artery first makes it easy to identify thefacial artery as it is the most important constantcollateral of the facial artery (Dupoirieux et al., 1999).Overall results in our study were satisfactory.

CONCLUSION

The FAMM flap is a reliable and versatile flap thatprovides like with the like tissue and is a good option forclosure of recurrent fistulae of the hard palate. Adaptationsin technique including a two-layer closure of the fistula andidentification of the facial artery with its inclusion along theentire length of a sufficientlywide pedicle will ensure successof the flap.

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