SURGICAL ONCOLOGY AND RECONSTRUCTION

Defect Components and Reconstructive

Options in Composite Orbitomaxillary
Defects With Orbital Exenteration
Shawn T. Joseph, MS, DNB,* Krishnakumar Thankappan, MS, DNB, MCh,y
Jimmy Mathew, MS, MCh,z Manju Vijayamohan, MDS,x Mohit Sharma, MS, MCh,k
and Subramania Iyer, MCh{
Purpose: The conventional way of reconstructing an orbital exenteration defect associated with a
maxillectomy is to cover it with a soft tissue free ap and camouage it with a spectacle-mounted orbital
prosthesis. Also, there are some reports on the use of bone aps. The objective of this study was to review
the reconstructive options for a defect resulting after orbital exenteration and maxillectomy.
Materials andMethods: This study concerns a retrospective case series of 20 patients. Electronic med-
ical records, including clinical details, operative notes, and follow-up data, were analyzed. Defects were
analyzed for their reconstructive components. The reconstructive methods used were studied by the types
of ap used, bony versus soft tissue types of reconstruction, and the prosthetic method used to rehabilitate
the eye. Outcomes were analyzed for ap success rate. Descriptive methods for data analysis were used.
Results: Fourteen patients underwent a soft tissue reconstruction alone and 6 underwent bony recon-
struction. The free rectus abdominis was the commonest soft tissue ap used. This article presents the
outcome of reconstruction in such patients and the utility of individual aps for their ability to replace
different components of the defect.
Conclusions: Ideal reconstruction should address all individual defect components of facial contour,
orbital, palatal, skull base, and skin defects. The free rectus abdominis ap remains the common choice.
When a composite socket reconstruction is to be achieved, the innovative free tensor fascia lata ap with
the iliac crest bone and internal oblique muscle is an option.
2014 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 72:1869.e1-1869.e9, 2014
The conventional way of reconstructing an orbital
exenteration defect associated with a maxillectomy
is to cover it with a soft tissue free ap, such as the
rectus abdominis, latissimus dorsi, or anterolateral
thigh (ALT) ap, and camouage it with a spectacle-
mounted orbital prosthesis. Also, there are some
reports on the use of bone aps, such as the thoraco-
dorsal angular artery (TDAA) ap and the deep circum-
ex iliac artery (DCIA) ap.
1-6
The objective of this
study was to review the reconstructive options for a
defect resulting after orbital exenteration and
maxillectomy with or without skull base resection.
This article also presents the outcome of recon-
struction in such patients and the utility of individual
aps for their ability to replace different components
of the defect.
Received from the Amrita University, Kochi, Kerala, India
*Assistant Professor, Department of Head and Neck Surgery,
Amrita Institute of Medical Sciences.
yAssociate Professor, Department of Head and Neck Surgery,
Amrita Institute of Medical Sciences.
zProfessor, Department of Head and Neck Surgery, Amrita
Institute of Medical Sciences.
xProfessor, Department of Prosthodontics, Amrita School of
Dental Sciences.
kProfessor and Head, Department of Head and Neck Surgery,
Amrita Institute of Medical Sciences.
{Department of Head and Neck Surgery, Amrita Institute of
Medical Sciences.
Address correspondence and reprint requests to Dr Thankappan:
Department of Head and Neck Surgery, Amrita Institute of Medical
Sciences, Kochi, India; e-mail: drkrishnakumart@yahoo.co.in
Received February 6 2014
Accepted April 23 2014
2014 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/00461-3$36.00/0
http://dx.doi.org/10.1016/j.joms.2014.04.029
1869.e1
Materials and Methods
This is a retrospective descriptive review of 20 pa-
tients. The study population underwent orbital exen-
teration and maxillectomy with or without skull base
resection for malignant sinonasal tumors. The study
period was January 2004 through December 2011.
All defects reconstructed in the series involved
bone and soft tissue of the maxilla, orbit, and hard
palate. All patients required complete orbital exenter-
ation. Only cases reconstructed with free aps were
included in this study. To address the research pur-
pose, electronic medical records, including clinical
details, operative notes, and follow-up data, were
analyzed. Institutional review board approval was ob-
tained for this review. Components of the defects
were categorized as facial contour defects, orbital
socket with rim and oor defects, palatal defects,
skull base defects, and skin decits on the anterior
maxillary surface. The reconstructive methods used
were studied by the types of ap used, bony versus
soft tissue types of reconstruction, and the prosthetic
method used to rehabilitate the eye. Outcomes
were analyzed for ap success rate. Individual aps
were studied for their ability to replace different
FIGURE 1. A, A 50-year-old woman with carcinoma of the left maxilla showing orbital and skin involvement. B, Palatal involvement.
C, Surgical defect of total maxillectomy with orbital exenteration. D, Frontal view of reconstructive outcome with a free rectus abdominis
ap 1 year after treatment. No orbital rehabilitation was chosen. (Fig 1 continued on next page.)
Joseph et al. Orbital Exenteration of Defect Reconstruction. J Oral Maxillofac Surg 2014.
1869.e2 ORBITAL EXENTERATION OF DEFECT RECONSTRUCTION
components of the defect. Descriptive data analysis
was used.
Results
Twenty patients (16 men and 4 women; mean age,
51.21 yr; age range, 32 to 85 yr) met the inclusion
criteria. Of these 20 patients, 14 underwent a soft tis-
sue reconstruction alone (free rectus abdominis ap in
9 and free ALT ap in 5). The free rectus abdominis
(Fig 1A-E) was the most common soft tissue ap
used. Six patients underwent bony reconstruction. A
bone free ap based on the tensor fascia lata muscle
(TFL), iliac crest bone (IC), and internal oblique mus-
cle (IO) and dual anastomosis was used in 4 patients
(Fig 2A-C). A free bula ap was used in 2 patients.
All 20 patients had facial contour defects from maxil-
lectomy and orbital cavity defects resulting from
orbital exenteration and orbital oor with rim defects.
All 20 patients also had palatal defects. Seven patients
had an additional skull base defect and 10 patients had
an anterior skin defect. Facial contour could be recon-
structed in all patients with a bony or a soft tissue ap.
Although all patients had an orbital rim and oor
defect, the cavity was re-created with a rim in only 5
patients. Cavity re-creation was possible only with
hard tissue reconstruction using bone. The palatal
defect was effectively eliminated in all patients using
the soft tissue component of the aps. Seven patients
who had an additional skull base defect underwent a
primary dural repair with a pericranial ap or fascia
lata. A vascularized muscle is essential to cover such
extensive skull base defects. The rectus abdominis
muscle was used in 5 patients and the vastus lateralis
muscle of the ALT ap was used in 2 patients. Ten pa-
tients also had anterior skin loss. The skin paddle of
the ap used was sufcient to cover these defects.
The details of defect components and the method of
reconstructing them are presented in Table 1. Five pa-
tients were rehabilitated with an orbital prosthesis, 5
had a spectacle-mounted prosthesis, and 2 had an
ocular prosthesis (Fig 3A-C). Eye rehabilitation was
not performed in 8 patients. Dental rehabilitation
was performed with conventional removable dentures
in 8. The remaining chose not to have any dental reha-
bilitation. Osseointegrated implants were not used in
any patient in this series. There was 1 ap loss
(TFL-IC-IO ap). One patient in whom a free rectus ab-
dominis ap was used died in the immediate postoper-
ative period. Excluding this patient, the ap success
rate was 18 of 19 (94.7%). Eleven patients were alive
and free of disease after a mean follow-up of 30.5
months (range, 6 to 76 months).
Discussion
The objective of this study was to review the recon-
structive options for a defect resulting from orbital
exenteration and maxillectomy with or without skull
base resection. This article also presents the outcome
of reconstruction in such patients and the utility of in-
dividual aps for their ability to replace different com-
ponents of the defect. Soft tissue reconstruction was
usually performed. The free rectus abdominis ap
was the commonest ap used. Bony reconstruction
is ideal but complex.
Reconstruction of an orbital exenteration defect
associated with maxillectomy, with or without skull
base resection, is a challenge. There are many compo-
nents of this complex orbitomaxillary defect.
1. Facial bony and soft tissue contour defect: Max-
illectomy can result in considerable loss of bulk
of the face, which has to be replaced with bone
or soft tissue reconstruction.
2. Orbital socket with walls: Commonly, the orbital
oor and medial wall form part of the defect.
Rarely, the lateral wall and the roof also are
included. Ideally, this area should be replaced
by bone. The medial orbital wall may not always
require reconstruction. Askin or soft tissuelined
socket is necessary to support a prosthesis to
rehabilitate the eye.
3. Palatal defect: Soft tissue to provide adequate or-
onasal separation is essential. A bony alveolar
reconstruction is ideal to provide dental rehabili-
tation.
FIGURE 1 (contd). E, Palatal obturation with the rectus abdomi-
nis muscle is well mucosalized.
Joseph et al. Orbital Exenteration of Defect Reconstruction. J Oral
Maxillofac Surg 2014.
JOSEPH ET AL 1869.e3
4. Skull base defect: Such a defect occurs when
maxillectomy is combined with craniofacial
resection.
5. Skin defect: Resection of maxillary tumors might
necessitate the excision of overlying skin, result-
ing in an anterior skin defect.
The reconstructive goals are to achieve adequate
cranionasal separation, oronasal separation, facial con-
tour skin cover, and orbital and dental rehabilitation.
Reconstructive options for such defects include a
soft tissue ap or a composite bone ap. Soft tissue
aps, when used alone, can eliminate the defect
and support the skull base defect, if any. It alsoprovides
oronasal separation and replaces any skin defect.
Although this can provide adequate contour defect
correction, a bone ap might be more ideal. A bone
ap also is needed to create an orbital cavity to retain
an orbital or ocular prosthesis without difculty. The
issue that has not been adequately addressed in the
available literature is the reconstruction of the bony
inferior orbital rim when the orbital contents are ab-
sent. The inferior orbital rim can be reconstructed us-
ing a bony reconstruction or a titanium mesh with
FIGURE 2. A, Illustration showing the scheme of reconstruction of the tensor fascia lata muscle, iliac crest bone, and internal oblique muscle
ap. B, Reconstructed eye socket with the tensor fascia lata muscle, iliac crest bone, and internal oblique muscle ap. C, Frontal view of recon-
structed outcome 1 year after treatment. An ocular prosthesis was used.
Joseph et al. Orbital Exenteration of Defect Reconstruction. J Oral Maxillofac Surg 2014.
1869.e4 ORBITAL EXENTERATION OF DEFECT RECONSTRUCTION
adequate soft tissue cover. Mesh must always be used
with a soft tissue ap to cover the inferior and superior
surfaces. However, the ap, when used, tends to cover
the mesh only on its inferior surface. To cover its supe-
rior surface, it has to be sandwiched between the mus-
cle paddle of the rectus abdominis or skin paddle of the
ALTap, these tendtobe bulky. Similarly, if bony recon-
struction of the inferior orbital rim is considered, the
same difculty of covering the superior surface of the
reconstructed bone and leaving the bare bone exists.
Combining these methods with the use of the tempora-
lis muscle to cover the superior surface of the bone or
the mesh is a possibility, but is hampered by the tech-
nical difculty of transferring the muscle through the
intact lateral orbital wall. Orbital and dental rehabilita-
tion also is an integral part of the treatment of such de-
fects. Prosthetic methods are commonly used. Orbital
rehabilitation can be performed with a spectacle-
mounted prosthesis, an orbital prosthesis, or an ocular
prosthesis. A spectacle-mounted prosthesis is straight-
forward to fabricate and wear, but the appearance is
quite articial and, when taken off, is not appealing.
An orbital prosthesis has the advantage of incorpo-
rating the adnexal structure, such as the eyelids, eye-
brows, and other areas of soft tissue deciency. The
disadvantage is that it requires good bony support
from all directions. It will require stabilization with
an adhesive or an osseointegrated implant. An ocular
prosthesis is ideal when the patient has the eyelids pre-
served and a good epithelial-lined cavity. An orbital or
ocular prosthesis requires an intact orbital oor.
Regarding dental rehabilitation, none of the patients
in this series opted for osseointegrated implants, and
most were given conventional removable dentures.
Some did not opt for any form of dental rehabilitation.
Speechand swallowing outcomes were not objectively
assessed in these patients. The conventional way of re-
constructing such a defect is to cover it with a soft tis-
sue ap. Hanasono et al
6
reported their experience of
7 patients who underwent orbital exenteration with
maxillectomy in a series of 79 patients with orbital
exenteration. The rectus abdominis myocutaneous
ap was used in 2 and the ALT ap was used in 5. No
patient underwent bony reconstruction for such de-
fects. Cordeiro and Chen
1
also recommended only
soft tissue reconstruction after orbital exenteration
for type IIIb and IVdefects according to their classica-
tion. A rectus abdominis myocutaneous free ap with
at least 1 skin island was their choice. Brown and
Shaw
7
also studied maxillectomy defects. For Class IV
defects, total maxillectomy with orbital exenteration
was usually reconstructed with a DCIA ap with an
IO or a TDAA ap with the latissimus dorsi muscle.
They suggested the temporalis, rectus abdominis, or la-
tissimus dorsi ap for Class V defects, with orbitomax-
illary defects of the palate preserved. Triana et al
3
reported on 25 patients with orbital exenteration and
maxillectomy. Alatissimus dorsi apused as a myocuta-
neous ap or with the scapula (osteomyocutaneous)
was the commonest ap in their series. Chepeha
et al,
8
intheir report of 19 patients withorbital exenter-
ation, described 6 patients with more than 30% of the
Table 1. DEFECT COMPONENTS AND FLAP RECONSTRUCTION
Defect Component Patients (n) Flap Used Flap Component Used n
Facial contour (bone and soft tissue) 20 rectus abdominis rectus muscle 9
ALT ALT soft tissue 5
TFL-IC-IO TFL bone and soft tissue 4
bula bula bone and soft tissue 2
Orbital socket with rim and oor 20 rectus abdominis rectus with rib and temporalis 1
TFL-IC-IO iliac crest bone with internal oblique muscle 4
none 15
Palatal defect 20 rectus abdominis rectus skin paddle 6
rectus abdominis rectus muscle alone 3
ALT ALT skin paddle 5
bula bula skin paddle 2
TFL-IC-IO TFL skin paddle 4
Skull base defect 7 rectus abdominis rectus muscle 5
ALT ALT vastus lateralis muscle 2
Skin defect 10 rectus abdominis rectus skin paddle 3
ALT ALT skin paddle 4
TFL-IC-IO TFL skin paddle 2
bula bula skin paddle 1
Abbreviations: ALT, anterolateral thigh; TFL-IC-IO, tensor fascia lata muscle, iliac crest bone, and internal oblique muscle.
Joseph et al. Orbital Exenteration of Defect Reconstruction. J Oral Maxillofac Surg 2014.
JOSEPH ET AL 1869.e5
orbital rim removed. These patients underwent recon-
struction with osseocutaneous scapula aps. A soft
tissue ap with an orbital or a spectacle-mounted pros-
thesis is not a perfect reconstructive method. There is
no rigid support at the infraorbital margin and oor.
Moreover, the prosthesis used may be difcult to handle
and mediocre in appearance. Attempts to t an ocular
prosthesis in the cavity formed by a muscle ap have
been hampered by the brosis that sets in to push out
the prosthesis. Options, such as the TDAA ap with
the latissimus dorsi and scapula and the DCIA ap
withthe IOand IC, may not provide adequate soft tissue
to cover the bony components in the orbital cavity. This
complex multiaxial reconstruction might be restricted
by the relative orientation of the bone, muscle, and
skinpaddle. Theseaps alsoareinferior whenthedefect
is associated with skin defects.
9
In the initial part of the study, only a soft tissue ap,
most commonly a rectus abdominis free ap, was
used. Although this ap adequately eliminated the cav-
ity, including the skull base defect, and provided skin
and palatal cover, it was grossly inadequate for re-
creating the orbital cavity and socket. Soft tissue aps
failed to replace the contour defect because of bone
loss. In these early cases, a spectacle-mounted or an
orbital prosthesis was used to cover the orbital defect.
In a series of maxillary reconstructions using primarily
the rectus abdominis ap, Olsen et al
10
reported
acceptable palatal closure, with most patients exhibit-
ing excellent masticator function. Use of the ALT ap
also has been well described in these cases.
11
The
criteria for palate closure with a soft tissue free ap
used by Funk et al
12
included sufcient residual denti-
tion to retain a dental prosthesis. During the latter part
FIGURE 3. A, Patient with carcinoma of the left maxilla reconstructed with a free bula ap. Bone was used only for alveolar reconstruction.
B, The orbital defect was closed with lid approximation and an orbital prosthesis was used. (Fig 3 continued on next page.)
Joseph et al. Orbital Exenteration of Defect Reconstruction. J Oral Maxillofac Surg 2014.
1869.e6 ORBITAL EXENTERATION OF DEFECT RECONSTRUCTION
of the study period, bone aps were used, which
restricted the use of soft tissue aps in elderly patients
who could undergo a lengthy surgical procedure. This
change was due to the inability to achieve good cosm-
esis with soft tissue aps. Over time, the soft tissue
aps would decrease in bulk and contract, thus
adversely affecting the cosmesis and placement of an
ocular prosthesis. The authors increasing experience
and good results during this period with the use of
bone aps for reconstructing the mandible coupled
with new literature emerging on the use of free vascu-
larized bone aps suggested reconstruction of the
maxilla using the free bula ap.
13-15
The free bula
ap had the advantage over soft tissue aps in
allowing for the re-creation of the malar prominence
and alveolar ridge, thus allowing for dental implants
later on. While trying to reconstruct the orbital oor
and alveolus (2 osteotomies), the bula ap was
considered unsatisfactory because of inadequate
pedicle length, necessitating the use of vascular grafts.
The bula ap had its limitations not only in providing
adequate soft tissue for reconstructing the maxillec-
tomy and orbit defects but also, more importantly, in
providing adequate dural seal when the skull base
was involved. The bula ap provides an option of
dental implantation later on, but the authors found
that most of these patients with advanced disease do
not opt for dental implants. The investigators of 2 large
series of bula ap for maxillectomy also concluded
that it is inadequate for Brown Class III and IV defects
because such defects are complicated by the problem
of the correct orientation of skin islands and soleus in-
sertions.
13,16
Although used in 2 patients in the present
series, the bone of the free bula ap was used
to reconstruct the alveolus only and the remaining
defect, including the orbital cavity, was lled with
the soft tissue component of the ap. Although it
may seem easy to reconstruct the orbital oor with
the segment of the bula, it is inadequate for
covering the superior bony surface of the bula
bone in the socket, forming skin, or forming a soft
tissuelined socket.
The authors experience with the use of the TFL-IC
ap in orbital oor reconstruction for maxillectomy
defects with a preserved eye has been reported.
17
The TFL-IC-IO ap is a further modication of that
ap.
9
This ap was used in 4 patients. The TFL-IC-IO
ap addresses all components of a maxillectomy
with an orbital exenteration defect. The IC provides
a rigid orbital rim for restoring shape and contour. A
vascular muscular bed provided by the IO that is sub-
sequently lined by a skin graft forms a cavity to hold
the ocular prosthesis very well. In addition to
providing the orbital rim and support, the ap pro-
vides a palatal defect cover and a form for the anterior
wall of the maxilla. The large skin paddle also can be
used for covering large cheek skin defects that occa-
sionally occur. The large amount of tissue that is har-
vested from the IC area can be a potential cause for
herniation of abdominal contents, but reinforcing the
defect with a thick polypropylene mesh can prevent
this. This ap requires dual anastomoses. The rst
anastomosis is performed between the DCIA and the
supercial temporal vessels. The second anastomosis
is performed between the TFL perforator from the
transverse branch of the lateral circumex artery,
which in turn is a branch of the profunda femoris ar-
tery or rarely the common femoral artery, and the
neck vessels. This provides good orbital oor support
and satisfactory midfacial cosmesis. Subsequently, an
ocular prosthesis can be t into the resultant cavity.
The upper eyelid closure is retained, but elevation is
compromised in these cases owing to the loss of func-
tion of the levator palpebrae superioris. This requires a
frontalis suspension immediately or at a later stage.
Articial dentures can be provided later on.
The TFL-IC-IO ap is a complex ap and is not
without problems. The pedicles of the TFL-IC-IO ap
are anastomosed to 2 different sets of pedicle. The
DCIA pedicle is short, but reaches the supercial tem-
poral vessels comfortably. Positioning of the IC and the
IO in the orbit permits extending the pedicle laterally
to the supercial temporal vessels. The second pedicle
from the TFL muscle is taken into the neck and anasto-
mosed to the facial vessels. This reach is just sufcient
and care is taken to dissect out the facial vessels quite
well into the face so that an extra length is obtained.
The pedicle length is a problem for the 2 pedicles,
but choosing the supercial temporal vessels as recip-
ient vessels compensates in part for the short pedicle.
Although the pedicle of the TFL ap is of adequate
FIGURE 3 (contd). C, Orbital prosthesis.
Joseph et al. Orbital Exenteration of Defect Reconstruction. J Oral
Maxillofac Surg 2014.
JOSEPH ET AL 1869.e7
length to reach the neck, the presence of the muscle
adjacent to the pedicle necessitates a larger tunnel to
accommodate it. The other issue with the ap is exten-
sive tissue loss at the donor site. Although meticulous
closure and a mesh prevented the incidence of hernia
in the present series, this possibility has to be accepted
as a potential complication.
Soft tissue reconstructioncombined witha spectacle-
mounted prosthesis is an option, but may be unsatisfac-
tory, especially ina younger patient witha disease witha
potentially long-term cure. In these cases, reconstruc-
tion of the inferior orbital rim and cover of the exenter-
ated orbital cavity will allow placement of an ocular
prosthesis. The authors recommend this type of com-
plex reconstruction only in patients who are younger
and have less aggressive tumors. In such patients, this
reconstruction will denitely add to the esthetics
and quality of life and may justify the added time and
complexity involved.
The literature on the use of IC aps shows a hetero-
geneous picture. Brown et al
18
presented 3 cases of
palatal reconstruction using a vascularized IC with an
IO ap and reported favorable functional results. The
common problems associated with the use of the IC
free ap in the maxilla are its excessive bulk, poor
skin paddle mobility in relation to bone, and short
pedicle length.
14,19
Table 2 presents a summary of
the relative utility of the rectus abdominis, ALT, free b-
ula, and TFL-IC-IO aps for fullling the goals of recon-
struction in such a reconstructive scenario.
Free microvascular tissue transfer has improved the
results of reconstruction of orbital exenteration de-
fects associated with maxillectomy. Ideal reconstruc-
tion should be able to address all individual defect
components of orbital, facial contour, palatal, skull
base, and skin defects. The free rectus abdominis ap
remains the common choice. When a composite
socket reconstruction is to be achieved, the innovative
free TFL-IC-IO ap is an option.
Acknowledgments
The authors express their sincere gratitude to the Graphics
Department, Amrita Institute of Medical Sciences, Kochi, India and
Mr Dinesh for their help in the preparation of the illustration.
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Table 2. UTILITY OF 4 MAJOR FLAPS FOR FULFILLING GOALS OF RECONSTRUCTION
Flap
Cranionasal
Separation
Oronasal
Separation
Facial
Contour
Dental
Rehabilitation
Orbital
Cavity
Orbital
Rehabilitation
Rectus abdominis yes yes unsatisfactory denture soft tissue ll only spectacle
ALT yes yes unsatisfactory denture soft tissue ll only spectacle or orbital
Free bula inadequate yes good denture and
dental implant
orbital rim without
soft tissue lining
spectacle or orbital
TFL-IC-IO yes yes good denture orbital cavity, bone
and soft tissue
ocular
Abbreviations: ALT, anterolateral thigh; TFL-IC-IO, tensor fascia lata muscle, iliac crest bone, and internal oblique muscle.
Joseph et al. Orbital Exenteration of Defect Reconstruction. J Oral Maxillofac Surg 2014.
1869.e8 ORBITAL EXENTERATION OF DEFECT RECONSTRUCTION
15. Yazar S, Cheng MH, Wei FC, et al: Osteomyocutaneous peroneal
artery perforator ap for reconstruction of composite maxillary
defects. Head Neck 28:297, 2006
16. Chang DW, Langstein HN: Use of the free bula ap
for restoration of orbital support and midfacial projection
following maxillectomy. J Reconst Microsurg 19:147,
2003
17. Iyer S, Chatni S, Kuriakose MA: Free tensor fascia lata-iliac
crest osteomusculocutaneous ap for reconstruction of com-
bined maxillectomy and orbital oor defect. Ann Plast Surg
68:52, 2012
18. Brown JS, Jones DC, Summerwill A, et al: Vascularized iliac crest
with internal oblique muscle for immediate reconstruction after
maxillectomy. Br J Oral Maxillofac Surg 40:183, 2002
19. Baliarsing AS, Kumar VV, Malik NA, et al: Reconstruction of max-
illectomy defects using deep circumex iliac artery-based com-
posite free ap. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 109:e8, 2010
JOSEPH ET AL 1869.e9