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. References 1. Cordeiro PG, Chen CM: A 15-year review of midface reconstruc- tion after total and subtotal maxillectomy: Part I. Algorithm and outcomes. Plast Reconstr Surg 129:124, 2012 2. Santamaria E, Cordeiro PG: Reconstruction of maxillectomy and midfacial defects with free tissue transfer. J Surg Oncol 94:522, 2006 3. Triana RJ Jr, Uglesic V, Virag M, et al: Microvascular free ap reconstructive options in patients with partial and total maxil- lectomy defects. Arch Facial Plast Surg 2:91, 2000 4. Pryor SG, Moore EJ, Kasperbauer JL: Orbital exenteration recon- struction with rectus abdominis microvascular free ap. Laryn- goscope 115:1912, 2005 5. Vergote T, Revol M, Servant JM, et al: Use of the free latissimus dorsi ap in the reconstruction of extensive orbital exentera- tions. Ann Chir Plast Esthet 37:525, 1992 6. Hanasono MM, Lee JC, Yang JS, et al: An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg 123:98, 2009 7. Brown JS, Shaw RJ: Reconstruction of the maxilla and midface: Introducing a new classication. Lancet Oncol 11: 1001, 2010 8. Chepeha DB, Wang SJ, Marentette LJ, et al: Restoration of the orbital aesthetic subunit in complex midface defects. Laryngo- scope 114:1706, 2004 9. Iyer S, Thankappan K, Kuriakose MA, et al: Tensor fascia lata-iliac crest-internal oblique free ap for composite orbito-maxillary defect with orbital exenteration. J Plast Reconstr Aesthet Surg 66:e116, 2013 10. Olsen KD, Meland NB, Ebersold MJ, et al: Extensive defects of the sinoorbital region: Results with microvascular reconstruc- tion. Arch Otolaryngol Head Neck Surg 118:828, 1992 11. Parkes WJ, Krein H, Heffelnger R, et al: Use of the anterolateral thigh in cranio-orbitofacial reconstruction. Plast Surg Int 2011: 941, 2011 12. Funk GF, Laurenzo JF, Valentino J, et al: Free-tissue transfer recon- struction of midfacial and cranio-orbito-facial defects. Arch Oto- laryngol Head Neck Surg 121:293, 1995 13. Futran ND, Wadsworth JT, Villaret D, et al: Midface reconstruc- tion with the bula free ap. Arch Otolaryngol Head Neck Surg 128:161, 2002 14. Peng X, Mao C, Yu GY, et al: Maxillary reconstruction with the free bula ap. Plast Reconstr Surg 115:1562, 2005 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