Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Arterialized Facial Artery Musculo-Mucosal Island Flap for Post-Oncological Tongue Reconstruction Alessandro Moro, PhD,  Gianmarco Saponaro, MD,  Piero Doneddu, MD,  Daniele Cervelli, MD,  Sandro Pelo, PhD,  Giulio Gasparini, MD,  Umberto Garagiola, MD, y Giuseppe D’Amato, MD,  and Mattia Todaro, MD  Background: In 1992, Pribaz described the facial artery muscu- lomucosal flap (FAMM), an axial musculomucosal flap based on the facial artery. The FAMM flap, a modification of the nasolabial and buccal mucosal flaps, is widely used in the reconstruction of defects in the oral cavity. Many modifications of this flap have been described in the literature. Here we aimed to explore the use of an arterialized tunnelized FAMM island flap (a-FAMMIF) for the reconstruction tongue defects after tumor resection. Method: From January 2015 to December 2016, five cases of tongue cancer were selected for the use of arterialized FAMMIF flap to reconstruct defects after tumor resection. Results: Reconstruction was successful in all cases, except one case of total flap necrosis; partial necrosis of the flap occurred in two patients, which were solved with medications. Conclusion: The authors consider the a-FAMMIF an unreliable flap in the reconstruction of tongue defects. The authors recommend avoiding tunneling and island modification when the vein is not included in the pedicle. Key Words: cheek flap, FAMM, musculomucosal flap, tongue reconstruction (J Craniofac Surg 2018;00: 00–00) T he goal of tongue reconstruction after tumor resection is to re- establish speech and swallowing. Many reconstructive options exist, including primary closure, skin and fat grafts, local flaps, regional flaps, and free flaps. Tongue defects can be easily reconstructed with myomucosal flaps based on the facial artery and vein. Local flaps harvested from the inside of the cheek and based on the facial or buccal vessels have gained importance due to their ‘like-to-like’ thin and pliable tissue, reliable blood supply, minimal donor site morbidity, and a wide range of movement. There is still considerable debate about the functional advan- tages of pedicled flaps reconstruction, as compared with free-flap or primary closure. Contrary to other buccal sub-sites, primary closure of the tongue is feasible only for very small defects, because even minor tethering might be functionally harmful. Today, microvas- cular free flaps are considered the workhorse in the reconstruction of the tongue, even though cutaneous free flaps are time-consum- ing, require surgical expertise in microsurgery, and are not always considered the best reconstruction option in such functional spe- cialized district as the oral cavity. For tongue defects that are too large for direct closure, but not so extended as to require free flaps, the facial artery musculo-mucosal (FAMM) flap is a versatile option and has many advantages compared with other reconstruction techniques. The FAMM flap was first described by Pribaz et al 1 in 1992 and is an axial flap based on the facial artery. FAMM flaps contain mucosa, submucosa, buccinator muscle, and facial vessels and can be inferiorly or superiorly based. The FAMM flap has been utilized in several applications, including post tumor ablation defects, cleft palate, osteoradionecrosis, lips reconstruction, nasal perforation, oropharynx, and nasopharyngeal stenosis. The FAMM flap has many advantages; first, it is a thin and pliable flap and conforms to the principle of ‘replace like-to-like’; it is a flap that requires a short dissection time and does not require two surgical teams; has a low morbidity of the donor site, and leaves no extra-oral scars; further- more, previous radiation therapy in the field of the flap is not a contraindication for flap use; 2–4 and has no retraction, even post- radiation therapy. 4,5 Based on our experience, the main disadvantages of the FAMM flap in tongue reconstruction are: the need for bite lock or tooth extraction; the need for secondary vestibuloplasty also in edentulous patients to guarantee a good prosthetic rehabilitation; in addition, the FAMM flap is not indicated when diffuse dysplasia of the oral cavity is present, 3 and the arch of rotation of the flap is wide, and the length:base ratio is good (5:1), but this is still a restriction for larger and anterior or contro-lateral tongue reconstruction. In the literature, there are a wide variety of proposed myomu- cosal cheek flaps for post oncological resection tongue reconstruc- tion. Tunnelling and island modifications have been advocated to avoid the above-mentioned limitations. 6,7 To fully understand this surgical technique, thorough knowledge of the anatomy of the region is of fundamental importance. The anatomy of the buccinator and facial vessels is well-described in the literature. 8 The facial artery branches from the external carotid artery and enters the face by crossing the inferior border of the mandible and ascending toward the nasal alae. It is located super- ficial to, and at the anterior aspect of the buccinator, deep to facial mimetic musculature. The facial artery supplies the buccinator through inferior and anterior buccal branches and ascends in the nasofacial groove to the medial canthus as the angular artery. Variations in the course of the facial artery exist and have been well-documented. 9,10 The facial artery and vein are nearby at the angle of the mandible but diverge superiorly. The facial artery and vein cross the superior border of the mandible at a mean distance of From the  Maxillofacial Surgery Unit, Faculty of Medicine, University Hospital ‘A. Gemelli,’ Catholic University of the Sacred Heart, Rome; and y Department of Biomedical, Surgical and Oral Sciences, School of Dentistry, University of Milan, Milan, Italy. Received January 2, 2018. Accepted for publication March 11, 2018. Address correspondence and reprint requests to Mattia Todaro, MD, Maxillofacial Surgery Unit, Faculty of Medicine, University Hospital ‘A. Gemelli,’ Catholic University of the Sacred Heart, Rome, Italy; E-mail: mattia.todaro@gmail.com The authors report no conflicts of interest. Copyright # 2018 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000004610 ORIGINAL ARTICLE The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018 1