Design of Buccinator Flaps for Oronasal Fistula Repair: A Technical Review and Case Series

Oronasal fistula (ONF) repair remains a significant challenge in patients with cleft lip and palate, particularly when local palatal tissue is insufficient. Regional flaps, including the buccal myomucosal flap (BMMF) and the facial artery musculomucosal (FAMM) flap, offer reliable reconstructive options. This study reviews the surgical anatomy, design, and clinical outcomes of these buccinator-based flaps in ONF repair.

This retrospective case series included 13 patients who underwent ONF repair using a BMMF or a FAMM flap between 2017 and 2024. Patient demographics, fistula characteristics, surgical details, postoperative care, and outcomes were collected and analyzed.

Six patients underwent BMMF reconstruction, while 7 received FAMM flaps. Successful fistula closure was achieved in 66.7% of patients in the BMMF group, with flap dehiscence occurring in 2 cases, both associated with digital manipulation. The FAMM flap cohort had a 100% fistula closure rate but exhibited a high incidence (86%) of postoperative scar contracture, with 4 patients requiring contracture release.

Based on this experience, the authors propose an algorithm for flap selection in ONF repair. Posteriorly based BMMFs are well suited for fistulas at the junction of the hard and soft palate (Type III) and the posterior third of the hard palate (Type IV). Superiorly based FAMM flaps are preferred for anterior ONFs, particularly those extending into the alveolus. The central hard palate remains a reconstructive challenge, with FAMM flaps offering better reach, though they require staged inset and debulking. Both BMMF and FAMM flaps provide vascularized tissue for ONF closure with minimal donor site morbidity. Strategic flap selection based on fistula location optimizes outcomes while mitigating complications.