Thursday, January 14, 2021
This protocol was last updated in 2016

General Considerations

  • Indications
    • The facial artery musculomucosal (FAMM) flap is a versatile intraoral flap that can be used for small to medium oral cavity defects, specifically floor of mouth, lateral tongue, and gingiva. The flap has also been used for nasal lining and the orbit. The flap is often used for palatal defects, whether there is a persistent fistula after previous cleft palate repair, or the result of trauma, cancer, etc. It is usually an interpolated flap, requiring a second stage to take down the pedicle. However, there are instances when the flap is inset into a defect and is a single stage procedure only.
  • Contraindications
    • A prior neck dissection with sacrifice of the facial artery.
    • Prior radiotherapy to the head and neck is a relative contraindication as blood flow to the flap may be compromised.
    • The flap is relatively thin, and if bulk is needed to reconstruct a defect, this flap is not indicated. Additionally, the flap is ~2 cm wide and is not indicated for larger wounds.
    • If a patient has full dentition, the flap is not typically used on the lingual side of the mandible. To circumvent this issue, teeth may be pulled or a bite block can be sewn in peri-operatively. Alternatively, the flap can be raised and a tunnel developed medial to the mandible. This requires complex pedicle dissection.
  • Pertinent anatomy
    • The flap is an axial musculomucosal flap. The facial artery is a branch of the external carotid artery, and the flap can be either an inferiorly based flap (traditional FAMM based on proximal facial artery) or superiorly based flap (based on retrograde flow through angular artery). The artery lies deep to the buccinator muscle and superficial to the risorius and zygomaticus muscles. There can be a variety of branching patterns distally and variation in terminal patterns. The flap is composed of mucosal layers, a portion of the buccinator muscles, and also a portion of the orbicularis oris muscle. Flap width is between 2.5 and 3 cm. The facial vein is not typically included in the flap, but a local plexus of veins allows for venous drainage. A Doppler probe can be used to aid in identification of the artery. The donor site can be closed primarily if possible. Other options for closure include skin grafting, donor graft material, buccal fat advancement, or healing by secondary intention.

Preoperative Preparation

  1. Evaluation
    • A careful history and physical examination should be undertaken to determine that there has been no prior neck surgery or radiation therapy that would contraindicate the flap.
  2. Potential Complications
    • Flap failure and loss of the paddle: Disruption of the critical perforator off the facial artery risks mucosal necrosis.
    • Injury to Stensen's duct.
    • Facial nerve injury
    • Difficulties with mastication due to loss of buccinator muscle.
    • Contracture of the intraoral mucosa or webbing.

Nursing Considerations

  1. Room Setup
    • Standard oral cavity procedure
  2. Instrumentation and Equipment
    • Major instrument tray #1, Otolaryngology
    • Major instrument tray #2, Otolaryngology
    • Bipolar forceps tray
  3. Medications (specific to nursing)
    • 1% lidocaine with 1:1000 epinephrine
    • Chlorhexidine
  4. Prep and Drape
    • Standard prep, 10% povidone iodine
    • Head drape
    • Towels to square off operative site including entire face and neck
    • Split sheet

Anesthesia Considerations

  1. General
    • The patient can likely be paralyzed for the procedure unless the staff says otherwise.
    • The patient is positioned supine and, in most cases, the bed will be turned 180° from the anesthesiologist.
    • In the vast majority of cases, the surgery is done under general anesthesia.

Operative Procedure

  1. Operative report example
    1. For reconstruction of the oral cavity defect, we performed facial artery musculomucosal flap based off the right facial artery. A Doppler was used to trace out the right facial artery. The papilla of the parotid duct was identified and marked to avoid any trauma to this structure. Our anticipated incision sites were marked out on the right cheek with the facial artery centered on this flap. The width of the flap being at least 2 cm in diameter to prevent venous congestion. Using Bovie cautery with a needle tip point, mucosa was cut starting superior and anteriorly. Buccinator muscle was divided. The facial artery was identified and clipped. We dissected superficial to the facial artery, raising our flap which contained the mucosa, submucosa, buccinator  muscle and facial artery. The flap was then rotated onto the floor of mouth defect covering the bone and floor of mouth defect. The flap was inset with horizontal 3-0 Vicryl sutures. The right cheek was closed primarily with horizontal 3-0 Vicryl sutures. The length of the facial artery musculomucosal flap was approximately 6 cm in length. There was no tongue tethering. The flap appeared well perfused without any signs of venous congestion at the completion of the procedure. The patient was turned back to anesthesia for emergence and extubation and escorted to the post operative recovery unit.

Postoperative Care

  1. Tension on the flap is minimized by restricting tongue mobility or talking if indicated. This should be reinforced in the postoperative orders.
  2. Takedown of the flap in our pediatric patients usually occurs 4-6 weeks after the 1st procedure. If a vertical cheek scar becomes problematic post-operatively, a revision z-plasty may be performed.

References

J. Pribaz et al. A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plastic Reconstructive Surgery. 1992 Sep;90(3):421-9.

Ayad et al. Facial artery musculomucosal flap in head and neck reconstruction: A systematic review. Head and Neck. 2015 Sep;37(9):1375-86. 

Joshi et al. Reconstruction of intraoral defects using facial artery musculomucosal flap. British Journal of Plastic Surgery. 2005 Dec;58(8):1061-6.