Masseter muscle flap for reconstruction of intra-oral defects in patients with early cancer of posterior-inferior parts of the oral cavity.

INTRODUCTION: Early carcinomas of the oral cavity in the posterior-inferior regions poses a challenge for reconstruction due to the lack of muscle support underneath and the limited space available to use some of the frequently-used flaps. OBJECTIVE: This study was done to evaluate the efficacy of the superiorly based masseter muscle flap in reconstruction of intra-oral post- ablation defects in patients with early oral carcinoma of the posterior-inferior part of the oral cavity. METHODS: A superiorly based masseter muscle flap were used to reconstruct the post-surgical intra- oral defect in 60 patients with early squamous cell carcinoma (T<4cm) of the posterior-inferior part of the oral cavity. The patients were followed up at 1-week and 1-month postoperatively to check for flap viability, complications, change in mouth opening and deviation of the mandible on mouth opening. To rule out any recurrence in the oral cavity masseter flaps, the patients were followed up for 1 year. RESULTS: The flap was viable in all patients and underwent mucosalization. 7/60 patients had postoperative infections, while 2/60 patients developed an oro-cutaneous fistula which required a secondary corrective procedure. The mean±standard deviation of change in mouth opening at 1 week postoperatively was +1.917±3.36mm, which increased to +2.633±2.95mm at 1 month after surgery. The Friedman test revealed that there was a statistically significant change in mouth opening from preoperative period to the1 week and 1 month postoperative periods (p=0.000). Female patients showed better improvement in mouth opening postoperatively. The ipsilateral deviation of the mandible on mouth opening was between 0-5mm in 39 patients, 5-10mm in 17 patients and more than 10mm in 4 patients. There were no recurrences noted in the masseter flaps used. CONCLUSION: The study infers that the superiorly based masseter muscle flap is a reliable method for reconstruction in early oral cancer patients yielding good functional results and acceptable cosmesis with nominal postoperative complications.

Combining an end to side nerve to masseter transfer with cross face nerve graft for functional upgrade in partial facial paralysis-an observational cohort study.

BACKGROUND: Results of a single stage technique combining cross facial nerve graft(s) (CFNG) with an ipsilateral end to side nerve to masseter transfer (NTM) in incomplete facial paralysis are assessed in a retrospective cohort study. The hypothesis is that the technique can safely improve the quality of smile in these patients. End to side coaptations for the recipient facial nerve minimise the risk of iatrogenic function loss, contrasting with the end to end neurorrhaphies used in conventional babysitting procedures. METHODS: A series of 27 patients was studied through case note review and standardised assessments. Surgical technique involves extensive exposure of the facial nerve and the NTM on the affected side and access is by bilateral preauricular incisions. End to end coaptations are made to the facial nerve on the donor side and on the recipient a standard CFNG is combined with an end to side NTM coaptation. Follow up was a minimum of 9 months from surgery. RESULTS: Overall improvement in the Sunnybrook scale averaged 33, from a pre-operative score of 40 (p < 0.05). Average upgrade of 4.7 mm of increased movement at the modiolus was achieved (p < 0.05), 43% improvement compared to the normal side. An improved resting symmetry of 3.8 mm was achieved in relevant cases. Where eye closure was strengthened the average improvement was 5 mm of increased lid closure. The smile achieved was spontaneous in 22 of 27 cases. CONCLUSION: The study confirms the hypothesis that CFNG with NTM transfer offers a physiological upgrade of facial movement in partial facial paralysis, applicable in both early and longstanding cases.

Dual innervation of free gracilis muscle for facial reanimation: What we know so far.

BACKGROUND: In the last decade, some institutions have begun combining the CFNG and masseteric nerve to provide dual innervation to the gracilis muscle for dynamic facial reanimation in facial paralysis patients. We reviewed the various ways that these two nerves have been coapted to provide dual innervation, and summarized the functional outcome for these methods. METHODS: A search of the Ovid EMBASE, MEDLINE, Cochrane, and Scopus databases was performed from 1946 to May 2019 for dual innervation of gracilis muscle using CFNG plus masseteric nerve for facial reanimation. RESULTS: A total of 184 articles were identified in the initial search, of which seven met our inclusion criteria. Three additional abstracts with 43 patients were identified but the level of details was not sufficient to include the results in the analysis. A total of 57 patients were reviewed (mean age of 42.1 years (6-79 years)). The majority of dual innervation procedures were performed using the ipsilateral masseteric nerve sutured end-to-end to the obturator nerve, and an additional CFNG connected end-to-side to the obturator nerve. In the 26 patients with Terzis scores available, there were no differences between masseteric nerve coapted end-to-end and CFNG as end-to-side to the obturator, or the reverse coaptation. All but two patients achieved function of the gracilis activated by the masseteric nerve within 2-5 months. CONCLUSIONS: This review shows that dual innervation of the gracilis is safe; and in some cases, does appear to provide early onset gracilis activation as well as an eventual spontaneous smile.

Masseteric to buccal branch nerve transfer.

PURPOSE OF REVIEW: To review recent literature pertaining to the use of masseteric-facial nerve neurorrhaphy (MFNN) for facial reanimation in patients with facial paralysis. RECENT FINDINGS: First, MFNN effectively restores some midface tone and function, including the ability to smile. Second, use of the masseteric nerve minimizes synkinesis, dysarthria, and dysphagia that frequently occur after hypoglossal-facial nerve neurorrhaphy. Third, concurrent cable grafting to the zygomatic branch from an intact proximal facial nerve remnant - when available - can restore dynamic eye closure. SUMMARY: Masseteric nerve transfer is an alternative to hypoglossal nerve transfer that improves midface appearance and function for properly selected patients with facial paralysis.

Oral cavity reconstruction with the masseter flap.

The purpose of this report is to highlight how an unusual, outdated, unpopular and overlooked reconstructive method such as the masseter flap can be a reliable, straightforward and effective solution for oral reconstruction in selected cases. We report the transposition of the masseter crossover flap in two previously pre-treated patients presenting a second primary oral squamous cell carcinoma; excellent functional results with satisfactory cosmetic appearance were obtained in both cases. In the literature, only 60 cases of oral cavity and oropharyngeal reconstructions using the masseter flap have been reported. The possible clinical utility of this flap, even in modern head and neck reconstructive surgery, is presented and discussed. We believe that the masseter flap should enter in the armamentarium of every head and neck surgeon and be kept in mind as a possible solution since it provides an elegant and extremely simple procedure in suboptimal cases for microvascular reconstruction.

Segmental masseteric flap for dynamic reanimation of facial palsy.

The masseter muscle is one of the major chewing muscles and contributes to define facial contour. It is an important landmark for aesthetic and functional surgery and has been used for facial palsy reanimation or as source of donor motor nerve. We present an anatomic study to evaluate the possibility of using a muscle subunit for dynamic eye reanimation. Sixteen head halves were dissected under magnification to study the neurovascular distribution and determine safe muscle subunits; areas of safe/dangerous dissection were investigated. Once isolated, the arc of rotation of the muscular subunit was measured on fresh body to verify the reach to the lateral canthus. The patterns of neurovascular distribution and areas of safe dissection were identified; the anterior third of the muscle represents an ideal subunit with constant nerve and artery distribution. The muscle is too short to reach the lateral canthus; a fascia graft extension is needed. The information provided identified the main neurovascular branches and confirms the feasibility of a dynamic segmental flap. The need of efficient motor units for facial reanimation demands for different surgical options. A detailed anatomic description of the neurovascular bundle is mandatory to safely raise a functional motor subunit.

Cross-facial nerve graft and masseteric nerve cooptation for one-stage facial reanimation: principles, indications, and surgical procedure.

BACKGROUND: The use of facial cross-grafting in acquired recent unilateral facial palsy provides spontaneity and emotional activation. Masseteric nerve for facial animation has mainly been described for reinnervation of neuromuscular transplants, babysitter procedures, or direct facial nerve cooptation. The simultaneous use in a single procedure of cross-facial nerve grafting and masseteric cooptation has not been described. METHODS: Eight patients underwent facial animation using single stage cross-facial nerve grafting and masseteric nerve cooptation. The mean duration of facial palsy was 10.2 months (range, 1-23 months). RESULTS: Voluntary contraction in response to masseteric nerve activation was observed after 2 to 4 months. All patients underwent postoperative rehabilitation and spontaneous contraction was achieved in 7 to 13 months postoperatively. Cosmetic outcomes were evaluated as moderate in 1 patient, good in 5 patients, and excellent in the remaining 2 patients. CONCLUSION: This new technique could provide good results with fast, reliable, and powerful reinnervation, spontaneity, and low morbidity.

Facial reanimation by staged, split masseter muscle transfer.

BACKGROUND: Facial paralysis of the lower face presents severe functional and aesthetic disturbance to patients. The gamut of facial paralysis correction is diverse and must be tailored to the patient. When nerve repair or free functional muscle transfer is unavailable, regional muscle transfer has become a staple in surgical management of facial paralysis. Previous masseter transfers relied on orbicularis oris attachment, which may be atrophic, adhered, or lengthened. Using fascia lata grafts, we describe the senior author's method of staged, split masseter transfer as a reliable method for reanimating the lower third of the face in appropriate candidates. METHODS: The staged, split masseter muscle transfer is a 3-part repair. The first stage places a hemioral fascia lata graft to act as an anchor reinforcement. The second stage transfers the split masseter muscle, suturing to the fascia lata reinforced oral commissure. The third stage, a reefing procedure, is performed 6 to 10 months later under local anesthesia to reinforce attachments. RESULTS: Six patients underwent the staged, split masseter muscle transfer. Mean age was 43 (15-67) years. Mean time to surgery from onset of deficit was 174 months (3 months to 65 years). All patients had significant improvement over preoperative symptoms. Symmetry was restored in repose. On movement, commissure excursion went from 0 to 6.67 mm in the superolateral vector. Of the 6 patients, 5 required an average of 1.5 outpatient revisions to achieve satisfactory results on average of 4.67 (4-127) months after the final stage. CONCLUSIONS: The staged, split masseter transfer is useful for restoring subtle reanimation in patients presenting with facial paralysis. The staged, split masseter transfer provides bulk and restores both static and dynamic function. We present a case series demonstrating excellent long-term functional results.

The use of virtual planning and navigation in the treatment of temporomandibular joint ankylosis.

Temporomandibular joint ankylosis is not common in our community but can occur as a result of severe facial trauma or significant connective tissue disorders such as rheumatoid arthritis, osteoarthritis and psoriatic arthritis, and unfortunately as a result of iatrogenic causes. Ankylosis surgery is aimed at gap arthroplasty and mobilization of the joints. However, the removal of the bony ankylosis and the production of a gap between the ramus of the mandible and the base of the skull is often difficult because of the size of the ankylosis and the anatomy on the inner aspect of the mandible. As a result of this, the author has found that surgical navigation has been useful with the removal of the ankylosis, both on the medial side of the mandible and the cranial base. Once the ankylosis has been freed and the mandible mobilized, the gap arthroplasty needs to be maintained or the release of the ankylosis will fail and the joints will re-ankylose. It is important to maintain the space produced by the arthroplasty but this is difficult when autogenous materials such as temporalis muscle, dermis fat and other like materials are used. The gap ultimately closes under the influence of the masseter and medial pterygoid muscles and the ankylosis may return. This case report presents three representative patients in whom ankylosis has been released and the gap reconstructed with a total alloplastic joint replacement. All patients have had their ankylosis removed with the aid of a navigation system and all patients have been reconstructed with bilateral Biomet prosthesis. One patient has had their implant selected using virtual planning and the production of templates to help with placement of the stock implant.

Static and dynamic repairs of facial nerve injuries.

The patient with facial paralysis presents a daunting challenge to the reconstructive surgeon. A thorough evaluation is key in directing the surgeon to the appropriate treatment methods. Aggressive and immediate exploration with primary repair of the facial nerve continues to be the standard of care for traumatic transection of the facial nerve. Secondary repair using dynamic techniques is preferred over static procedures, because the outcomes have proved to be superior. However, patients should be counseled that facial movement and symmetry are difficult to mimic and none of the procedures described is able to restore all of the complex vectors and overall balance of facial movement and expression.

The pedicled masseter muscle transfer for smile reconstruction in facial paralysis: repositioning the origin and insertion.

BACKGROUND: The pedicled masseter muscle transfer (PMMT) is introduced as a new reconstructive option for dynamic smile restoration in patients with facial paralysis. The masseter muscle is detached from both its origin and insertion and transferred to a new position to imitate the function of the native zygomaticus major muscle. METHODS: Part one of this study consisted of cadaveric dissections of 4 heads (eight sides) in order to determine whether the masseter muscle could be (a) pedicled solely by its dominant neurovascular bundle and (b) repositioned directly over the native zygomaticus major. The second part of the study consisted of clinical assessments in three patients in order to confirm the applicability of this muscle transfer. Commissure excursion and vector of contraction following PMMT were compared to the non-paralyzed side. RESULTS: In all eight sides, the masseter muscles were successfully isolated on their pedicle and transposed on top of and in-line with the ipsilateral zygomaticus major. The mean length of the masseter and its angle from Frankfurt's horizontal line after transposition compared favorably to the native zygomaticus major muscle. In the clinical cases, the mean commissure movements of the paralyzed and normal sides were 7 mm and 12 mm respectively. The mean angles of commissural movement for the paralyzed and normal sides were 62° and 59° respectively. CONCLUSIONS: The PMMT can be used as a dynamic reconstruction for patients with permanent facial paralysis. As we gain experience with the PMMT, it may be possible to use it as a first-line option for patients not eligible for free micro-neurovascular reconstruction.

Transposition of the hemimasseteric muscle for dynamic rehabilitation of facial paralysis.

BACKGROUND: The masseter muscle is one of the muscles involved in mastication. Transposition of this muscle has been used for dynamic reanimation of facial palsy since the early years of the 20th century. We present an anatomic study of the masseter muscle and its neurovascular bundle to determine the possibility of using hemimasseteric transposition of the muscle for the rehabilitation of facial paralysis. METHODS: Six white fresh cadavers were used to study the masseter nerve and the vascular supply to the masseteric muscle. Dissection was performed in each hemiface of each specimen. All the masseter nerve bundles were dissected to study their distribution. ANATOMIC STUDY: A constant anatomy was examined in all the specimens dissected. Dissection was performed inside the muscle body to expose the whole masseter nerve and its branches. A tree-like design of the nerve branches was observed. Each nerve branch was accompanied by its corresponding vascular pedicle, which guaranteed the vascular supply to the muscle divisions. CONCLUSIONS: The knowledge of the anatomy of the masseter nerve and its vascular supply is the key to preventing nerve damage when the muscle is split for facial reanimation. The possibility of selecting the bundle included in the transposed section of the muscle could be used for dynamic reanimation of the paralyzed face.

The motor nerve to the masseter muscle: an anatomic and histomorphometric study to facilitate its use in facial reanimation.

INTRODUCTION: The motor nerve to the masseter muscle is increasingly being used for facial reanimation procedures. However, many surgeons have been reluctant to use this versatile source of axons because of difficulty in locating it intraoperatively. In this study we conducted a detailed assessment of its gross and microscopic anatomy and develop a simple, reliable method for locating this nerve. METHODS: We defined the anatomy of the nerve to the masseter, in particular its relationship to common surgical landmarks such as the auricular tragus and the zygomatic arch, and determined its intramuscular anatomy. We also performed a histomorphometric analysis. RESULTS: The anatomy of the motor nerve to the masseter was consistent. A convenient starting point for its dissection was found 3.16 ± 0.30 cm anterior to the tragus at a level 1.08 ± 0.18 cm inferior to the zygomatic arch. The nerve was located 1.48 ± 0.19 cm deep to the superficial muscular aponeurotic system (SMAS) at this point. Relative to the zygomatic arch, the nerve formed an angle of 50 ± 7.6° as it coursed distally into the masseter muscle. The distance from the arch to the first branch of the motor nerve to the masseter was 1.33 ± 0.20 cm. The histomorphometric analysis demonstrated that the motor nerve to the masseter contained an average of 2775 ± 470 myelinated fibers. CONCLUSIONS: Successful intraoperative location of the motor nerve to the masseter is facilitated by knowledge of its anatomy relative to standard surgical landmarks. A consistent and convenient starting point for dissection of this nerve is found 3 cm anterior to the tragus and 1 cm inferior to the zygomatic arch. The nerve contains over 2700 myelinated fibers, demonstrating its usefulness as a source of motor innervation for facial reanimation.

[Microneurovascular facial reanimation via the masseteric nerve: reconstruction alternative for long-standing facial palsy]. / Mikroneurovaskuläre Gesichtsreanimation über den N. massetericus : Rekonstruktionsalternative bei lang bestehender Fazialisparese.

BACKGROUND: The aim of the study was to retrospectively analyze the functional outcomes of microneurovascular facial reanimation using the masseteric innervation. PATIENTS AND METHODS: Seventeen patients with irreparable facial paralyses resulting from benign lesions involving the facial nuclei (n=14) or Möbius syndrome (n=3) were treated with free muscle flaps for oral commissural reanimation using ipsilateral masseteric innervation and using temporalis muscle transfer for eyelid reanimation. The results were analyzed by a commissural excursion (CE) index and a patient self-evaluation score. The presence of synkinesis was documented. Follow-up ranged from 8 to 48 months (mean 26.4 months). RESULTS: Normalization of the CE index could be observed in 8 out of 17 patients (47%), an improvement in 7 out of 17 (41%) and failure in 2 out of 17 (12%). A natural smiling response was observed in 10 out of 17 (59%) patients. Patient self-evaluation scores were a level higher than objective indices. CONCLUSIONS: Innervation of free muscle flaps with the masseteric nerve for oral commissure reanimation might play an important role in patients with long-standing facial palsy (as in Möbius syndrome). Synkinesis persists for long periods after surgery. However, most of the patients had learned to express their emotions by overcoming this phenomenon. Despite hypercorrection or inadequate correction, patients evaluate themselves favorably.

Outcomes of microneurovascular facial reanimation using masseteric innervation in patients with long-standing facial palsy resulting from cured brainstem lesions.

BACKGROUND: The functions of the human face are not only of esthetic significance but also extend into metaphoric nuances of psychology. The loss of function of one or both facial nerves has a remarkable impact on patients' lives. OBJECTIVE: To retrospectively analyze the functional outcomes of microneurovascular facial reanimation using masseteric innervation. METHODS: Seventeen patients with irreparable facial paralysis resulting from benign lesions involving the facial nuclei (n = 14) or Möbius syndrome (n = 3) were treated with free muscle flaps for oral commissural reanimation using ipsilateral masseteric innervation and using temporalis muscle transfer for eyelid reanimation. Results were analyzed by the absolute commissural excursion and commissural excursion index and by a patient self-evaluation score. Presence of synkinesis was documented. Follow-up ranged from 8 to 48 months (mean, 26.4 months). RESULTS: Normalization of the commissural excursion index was observed in 8 of 17 patients (47%), an improvement was seen in 7 of 17 (41%), and failure was observed in 2 of 17 (12%). The individual dynamics of absolute commissural excursion and commissural excursion index changes are presented. A natural smiling response was observed in 10 of 17 patients (59%) but not in the remaining 7 (41%). This response reflected the patient's ability to relay the natural emotion of smiling through the masseteric nerve. Patients' self-evaluation scores were a level higher than objective indices. CONCLUSIONS: Innervation of free muscle flaps with the masseteric nerve for oral commissure reanimation might play an important role in patients with lesions of the facial nuclei (as in Möbius syndrome). Synkinesis persists for long periods after surgery. However, most of the patients learned to express their emotions by overcoming this phenomenon. Despite hypercorrection or inadequate correction, patients evaluated themselves favorably.

A new composite hemiface/mandible/tongue transplantation model in rats.

Extensive head and neck deformities, including bone and soft tissue defects, are always challenging for reconstructive surgeons. The purpose of this study was to extend the application of the face/scalp transplantation model in rats by the incorporation of vascularized mandible, masseter and tongue (based on the same vascular pedicle), and to use this as a model to test new reconstructive options for extensive head and neck deformities with involving large soft and bone tissue defects.A total of 10 composite hemiface/mandible/tongue transplantations were performed in Lewis rats (RT1). Hemimandibular bone, masseter muscle, tongue and hemifacial skin flaps were dissected based on the same vascular pedicle of common carotid artery and external jugular vein. The flaps were then transplanted to the recipient inguinal region. Evaluation methods included flap angiography, plain x-ray, computed tomographic scan, and histology.All transplants survived indefinitely and no graft loss was noted. Flap angiography demonstrated intact vascular supply to the bone. Computed tomography scan and bone histology confirmed the viability of the bone components for the composite grafts. Hematoxylin and eosin staining determined the presence of viable bone marrow cells within the transplanted mandible. Viability of the tongue was confirmed by the presence of pink color and bleeding after puncture, as well as by histology.We have introduced a new composite hemiface/mandible/tongue transplant model. The main advantage of this model is the presence of vascularized bone marrow within the mandibular component, which may facilitate future studies on chimerism and tolerance induction. Although this mandible composite allograft is placed heterotopically to the recipient inguinal region, we believe that it may serve as a new reconstructive option for the coverage of combined bone and soft tissue defects within the head and neck region.

The combination of muscle transpositions and static procedures for reconstruction in the paralyzed face of the patient with limited life expectancy or who is not a candidate for free muscle transfer.

BACKGROUND: In long-standing complete and irreversible facial palsy where reconstruction by nerve grafting alone is no longer sufficient, reconstruction by dynamic procedures such as muscle transplantation or muscle transposition is required. The authors present the results obtained by regional muscle transposition for reconstruction of eye closure and smile in patients with irreversible facial palsy. METHODS: Twenty-nine patients treated by temporalis transposition for the eye and eight patients treated by masseter transposition for the mouth are presented. Assessment of outcome was based on clinical examination and analysis of facial movements by three-dimensional video analysis. RESULTS: Preoperatively, the paretic eye fissure was on average 2.30 +/- 2.17 mm wider than the healthy one. The difference was reduced postoperatively to 0.95 +/- 1.89 mm. Paralytic lagophthalmus during closure of the eyes was 9.59 +/- 3.03 mm preoperatively and was reduced postoperatively to 4.33 +/- 2.68 mm. Ocular tearing and desiccation were reduced drastically in all patients. Static asymmetry of the mouth corner improved from 14.17 +/- 5.26 mm preoperatively to 5.38 +/- 3.23 mm postoperatively. The index of dynamic symmetry improved from -0.17 +/- 0.25 preoperatively to 0.18 +/- 0.19 postoperatively. This means that, postoperatively, the amplitude of motion on the reconstructed side reached 18 +/- 19 percent that of the amplitude on the healthy side, whereas preoperatively a shift of the paralyzed mouth corner toward the healthy side occurred. CONCLUSIONS: Muscle transposition improves static symmetry and provides dynamic activity to a certain degree. It is therefore a valuable concept for patients with limited life expectancy.

Dynamic muscle transfer in facial reanimation.

Dynamic muscle transfers offer the hope of improved facial support and symmetry, with volitional movement. These are most commonly employed for reanimation of the oral commissure to produce a smile. In addition, muscle transfers have been used successfully to reestablish eye closure. Facial paralysis of long-standing duration presents challenges quite distinct from paralysis that is managed early after onset. It is in this situation, most commonly, that dynamic muscle transfers are used. In this respect, the alternative is free tissue transfer. Each of these two options have advantages and disadvantages.

Advances in facial reanimation.

PURPOSE OF REVIEW: Facial paralysis often has a significant emotional impact on patients. Along with the myriad of new surgical techniques in managing facial paralysis comes the challenge of selecting the most effective procedure for the patient. This review delineates common surgical techniques and reviews state-of-the-art techniques. RECENT FINDINGS: The options for dynamic reanimation of the paralyzed face must be examined in the context of several patient factors, including age, overall health, and patient desires. The best functional results are obtained with direct facial nerve anastomosis and interpositional nerve grafts. In long-standing facial paralysis, temporalis muscle transfer gives a dependable and quick result. Microvascular free tissue transfer is a reliable technique with reanimation potential whose results continue to improve as microsurgical expertise increases. Postoperative results can be improved with ancillary soft tissue procedures, as well as botulinum toxin. SUMMARY: The paper provides an overview of recent advances in facial reanimation, including preoperative assessment, surgical reconstruction options, and postoperative management.

Superiorly based and island masseter muscle flaps for repairing oropharyngeal defects.

INTRODUCTION: Tumours of the posterior part of the mouth and/or the oropharynx are often diagnosed at advanced stages. Reconstruction in this region has advanced considerably during the last three decades. Although microsurgery has offered major progress and has obviously improved the patients' outcome, the use of local and regional flaps generally remains an ideal solution for reconstruction. MATERIAL AND METHODS: Between January 1994 and December 2001, the defects resulting from resection in 22 out of 38 patients with retromolar and/or anterior faucial pillar squamous cell carcinomas treated at this institution, were repaired by one of two types of masseter muscle flaps. The first type is the superiorly based or cross-over masseter muscle flap, and the second type the island muscle flap (being a modification of the first type). RESULTS: The superiorly based masseter muscle flap was used in 12 patients and the island masseter muscle flap in 10. Both techniques offer a quick and reliable method for repairing oropharyngeal defects in oncologically "safe" cases. Neither require elaborate technique or aftercare. CONCLUSION: The island masseter muscle flap has an advantage over the superiorly based masseteric flap, as it is more flexible, pliable for larger defects, and causes no postoperative trismus.