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Posteriorly Based Buccal Artery Myomucosal Flap For Cleft Palate Repair: An Anatomical Study
Majid Rezaei, DDS MSc, Brian Figueroa, MD, Richard Drake, PhD, Francis Papay, MD, Bahar Bassiri Gharb, MD, PhD, Antonio Rampazzo, MD, PhD.
Cleveland Clinic Foundation, Cleveland, OH, USA.

Purpose:
The Buccinator myomucosal flap is a versatile flap for lengthening and repair of cleft palate defects. Posteriorly-based pedicled flaps are supplied either by the buccal artery or a branch of the facial artery. Clinical applications of this flap have been well reported in the literature, however few anatomical studies have shed light on the main pedicle and the vasculature within the flap. Therefore, the aim was to study the buccal neurovascular pedicle in order to design a new posteriorly based island flap.
Methods:
Dissections were performed in 11 fresh adult cadavers. External carotid (3 cadavers) or buccal (8 cadavers) artery was isolated and injected with red latex. In addition, indocyanine green (ICG) was injected directly into the buccal artery in 6 hemifaces and ICG angiography was performed before the application of latex. Entrance of the buccal neurovascular bundle into the flap was localized and marked intra-orally. Diameter of the buccal nerve and artery, flap length (distance from pterygomandibular raphe (PTM) to the corner of the mouth) horizontal distance from PTM to the pedicle entrance, and vertical distance of the pedicle entrance from maxillary tuberosity was measured with a digital caliper. Then, the whole mucosa and underlying soft tissue of the cheek area was harvested and examined with the surgical microscope in order to study the microanatomy of the flap.
Results:
The mean diameter of buccal artery and nerve was 0.95±0.29 mm and 1.29±0.20 mm, respectively. The Average diameter of the communicating branch with the facial artery was 0.62±0.22 mm. The mean vertical distance from the pedicle to the maxillary tuberosity was
11.57±3.87 mm. Flap length was on average 67.51±8.82 mm and the neurovascular pedicle entered the flap 11.38±2.87 mm anterior to the PTM, located in the posterior 1:6 of the flap. Buccal artery and nerve advanced inside the flap as much as 66.8%±6.0% and 67.3%±5.8% of the total flap length. On average, the buccal artery started branching 3.8±0.8 mm distal to its entrance point. The mean number of main branches of buccal artery was 3.25±0.8. There were 2 collateral veins paralleling the Buccal artery in the main pedicle. ICG angiography showed that 84.8%± 13.9% (mean±SD) of the flap length was instantly vascularized through the buccal arterial system.
Conclusion:
Our results demonstrated a consistent presence of the buccal artery in all dissected flaps. Its relatively large diameter and extensive branching toward the corner of the mouth, evidenced by ICG angiography, would allow the harvest of an island flap based only on the buccal artery. This would avoid a second stage for the division of the pedicle of the flap after primary cleft palate repair.


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