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Necker FN, Cholok DJ, Fischer MJ, Shaheen MS, Gifford K, Januszyk M, Leuze CW, Scholz M, Daniel BL, Momeni A. HoloDIEP-Faster and More Accurate Intraoperative DIEA Perforator Mapping Using a Novel Mixed Reality Tool. J Reconstr Microsurg 2024. [PMID: 39038461 DOI: 10.1055/s-0044-1788548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND Microsurgical breast reconstruction using abdominal tissue is a complex procedure, in part, due to variable vascular/perforator anatomy. Preoperative computed tomography angiography (CTA) has mitigated this challenge to some degree; yet it continues to pose certain challenges. The ability to map perforators with Mixed Reality has been demonstrated in case studies, but its accuracy has not been studied intraoperatively. Here, we compare the accuracy of "HoloDIEP" in identifying perforator location (vs. Doppler ultrasound) by using holographic 3D models derived from preoperative CTA. METHODS Using a custom application on HoloLens, the deep inferior epigastric artery vascular tree was traced in 15 patients who underwent microsurgical breast reconstruction. Perforator markings were compared against the 3D model in a coordinate system centered on the umbilicus. Holographic- and Doppler-identified markings were compared using a perspective-corrected photo technique against the 3D model along with measurement of duration of perforator mapping for each technique. RESULTS Vascular points in HoloDIEP skin markings were -0.97 ± 6.2 mm (perforators: -0.62 ± 6.13 mm) away from 3D-model ground-truth in radial length from the umbilicus at a true distance of 10.81 ± 6.14 mm (perforators: 11.40 ± 6.15 mm). Absolute difference in radial distance was twice as high for Doppler markings compared with Holo-markings (9.71 ± 6.16 and 4.02 ± 3.20 mm, respectively). Only in half of all cases (7/14), more than 50% of the Doppler-identified points were reasonably close (<30 mm) to 3D-model ground-truth. HoloDIEP was twice as fast as Doppler ultrasound (76.9s vs. 150.4 s per abdomen). CONCLUSION HoloDIEP allows for faster and more accurate intraoperative perforator mapping than Doppler ultrasound.
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Affiliation(s)
- Fabian N Necker
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
- Digital Anatomy Lab, Faculty of Medicine, Institute of Functional and Clinical Anatomy, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - David J Cholok
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Marc J Fischer
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
| | - Mohammed S Shaheen
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Kyle Gifford
- Department of Radiology, 3D and Quantitative Imaging, Stanford University School of Medicine, Stanford, California
| | - Michael Januszyk
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Christoph W Leuze
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
| | - Michael Scholz
- Digital Anatomy Lab, Faculty of Medicine, Institute of Functional and Clinical Anatomy, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Bruce L Daniel
- Department of Radiology, Stanford IMMERS (Incubator for Medical Mixed and Extended Reality at Stanford), Stanford University School of Medicine, Palo Alto, California
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
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Sullivan J, Skladman R, Varagur K, Tenenbaum E, Sacks JL, Martin C, Gordon T, Murphy J, Moritz WR, Sacks JM. From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier. J Reconstr Microsurg 2024; 40:398-406. [PMID: 37884060 DOI: 10.1055/a-2199-3870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Augmented reality (AR) and virtual reality (VR)-termed mixed reality-have shown promise in the care of operative patients. Currently, AR and VR have well-known applications for craniofacial surgery, specifically in preoperative planning. However, the application of AR/VR technology to other reconstructive challenges has not been widely adopted. Thus, the purpose of this investigation is to outline the current applications of AR and VR in the operative setting. METHODS The literature pertaining to the use of AR/VR technology in the operative setting was examined. Emphasis was placed on the use of mixed reality technology in surgical subspecialities, including plastic surgery, oral and maxillofacial surgery, colorectal surgery, neurosurgery, otolaryngology, neurosurgery, and orthopaedic surgery. RESULTS Presently, mixed reality is widely used in the care of patients requiring complex reconstruction of the craniomaxillofacial skeleton for pre- and intraoperative planning. For upper extremity amputees, there is evidence that VR may be efficacious in the treatment of phantom limb pain. Furthermore, VR has untapped potential as a cost-effective tool for microsurgical education and for training residents on techniques in surgical and nonsurgical aesthetic treatment. There is utility for mixed reality in breast reconstruction for preoperative planning, mapping perforators, and decreasing operative time. VR has well- documented applications in the planning of deep inferior epigastric perforator flaps by creating three-dimensional immersive simulations based on a patient's preoperative computed tomography angiogram. CONCLUSION The benefits of AR and VR are numerous for both patients and surgeons. VR has been shown to increase surgical precision and decrease operative time. Furthermore, it is effective for patient-specific rehearsal which uses the patient's exact anatomical data to rehearse the procedure before performing it on the actual patient. Taken together, AR/VR technology can improve patient outcomes, decrease operative times, and lower the burden of care on both patients and health care institutions.
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Affiliation(s)
- Janessa Sullivan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Kaamya Varagur
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Elijah Tenenbaum
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jacob L Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Terry Gordon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - John Murphy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - William R Moritz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Timóteo R, Pinto D, Martinho M, Gouveia P, Lopes DS, Mavioso C, Cardoso MJ. Skin deformation analysis for pre-operative planning of DIEAP flap reconstruction surgery. Med Eng Phys 2023; 119:104025. [PMID: 37634903 DOI: 10.1016/j.medengphy.2023.104025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 08/29/2023]
Abstract
Deep inferior epigastric artery perforator (DIEAP) flap reconstruction surgeries can potentially benefit from augmented reality (AR) in the context of surgery planning and outcomes improvement. Although three-dimensional (3D) models help visualize and map the perforators, the anchorage of the models to the patient's body during surgery does not consider eventual skin deformation from the moment of computed tomography angiography (CTA) data acquisition until the position of the patient while in surgery. In this work, we compared the 3D deformation registration from supine arms down (CTA position) to supine with arms at 90° degrees (surgical position), estimating the patient's skin deformation. We processed the data sets of 20 volunteers with a 3D rigid registration tool and performed a descriptive statistical analysis and statistical inference. With 2.45 mm of root mean square and 2.89 mm of standard deviation, results include 30% cases of deformation above 3 mm and 15% above 4 mm. Pose transformation deformation indicates that 3D surface data from the CTA scan position differs from data acquired in loco at the surgical table. Such results indicate that research should be conducted to construct accurate 3D models using CTA data to display on the patient, while considering projection errors when using AR technology.
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Affiliation(s)
- Rafaela Timóteo
- Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - David Pinto
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - Marta Martinho
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - Pedro Gouveia
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal; Faculdade de Medicina de Lisboa, Av. Prof. Egas Moniz MB, 1649-028 Lisboa, Portugal.
| | - Daniel Simões Lopes
- Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal; INESC ID, Rua Alves Redol 9, 1000-029 Lisboa, Portugal; ITI/LARSyS, Hub Criativo do Beato, Factory Lisbon, Rua da Manutenção 71, Building F S05, 1900-500 Lisboa, Portugal.
| | - Carlos Mavioso
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
| | - Maria João Cardoso
- Breast Unit/Digital Surgery Lab, Champalimaud Clinical Centre/Champalimaud Foundation, Avenida Brasília, 1400-038 Lisboa, Portugal.
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Tang Y, Guo Q, Li X, Huang Y, Kuang W, Luo L. Augmented reality-assisted systematic mapping of anterolateral thigh perforators. BMC Musculoskelet Disord 2022; 23:1047. [PMID: 36457082 PMCID: PMC9716696 DOI: 10.1186/s12891-022-06013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE In soft tissue reconstructive surgery, perforator localization and flap harvesting have always been critical challenges, but augmented reality (AR) has become a dominant technology to help map perforators. METHODS The lateral circumflex femoral artery (LCFA) and its perforators were reconstructed by CTA in consecutive patients (N = 14). Then, the anterolateral thigh perforators and the points from which the perforators emerged from the deep fascia were marked and projected onto the skin surface. As the virtual images were projected onto patients according to bony markers, the courses of the LCFA and its perforators were depicted on the skin surface for intraoperative guidance. Finally, the locations of the emergence points were verified by intraoperative findings and compared to those determined by handheld Doppler ultrasound. RESULTS The sources, locations, and numbers of perforators were determined by CTA. The perforators and their emergence points were accurately mapped on the skin surface by a portable projector to harvest the anterolateral thigh perforator flap. During the operation, the accuracy of the CTA & AR method was 90.2% (37/41), and the sensitivity reached 97.4% (37/38), which were much higher than the corresponding values of Doppler ultrasound. Additionally, the differences between the AR-marked points and the intraoperative findings were much smaller than those seen with Doppler ultrasound (P < 0.001). Consequently, all of the flaps were well designed and survived, and only one complication occurred. CONCLUSION Augmented reality, namely, CTA combined with projection in this study, plays a vital and reliable role in locating the perforator emergence points and guiding the procedure to harvest flaps and has fewer potential risks.
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Affiliation(s)
- Yifu Tang
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Qiang Guo
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Xiaoning Li
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Yuzhao Huang
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Wei Kuang
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
| | - Ling Luo
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Third Xiangya Hospital, Central South University, No. 138, Tongzipo Road Changsha, Hunan, China
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Konoeda H, Uematsu M, Jumxiao N, Masamune K, Sakurai H. A trial to visualize perforators images from CTA with a tablet device: experience of operating on minipigs. Comput Assist Surg (Abingdon) 2022; 27:120-127. [PMID: 35930262 DOI: 10.1080/24699322.2022.2104172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
A reliable method for precise perforator mapping can be extremely valuable in perforator flap surgery. In this study, we attempted to map perforator location using 3-dimensional computed tomography angiography (CTA), a newly developed application, and a tablet device. Preliminary examinations to test the device were conducted in mini-pigs. We used 5 female mini-pigs. Preoperative imaging of the vasculature was undertaken with CTA in the prone position, following Iopamidol (200 ml) injection via the internal jugular vein. Prior to the examination, we placed round markers on the backs of the mini-pigs. To assess accuracy, we compared the perforator positions acquired with an optical position measurement device with the perforator positions acquired with the tablet device. Furthermore, we compared the perforator positions with the tablet navigation device, which we measured directly. We measured 12 perforators with the optical position measurement device. The mean difference was 10 mm (minimum, 2 mm; maximum, 20 mm). We measured these perforators with the tablet navigation device. The mean difference was 5.4 mm (minimum, 0 mm; maximum, 20 mm). The perforator flaps were elevated safely. The perforator flaps could be elevated safely using our device, as the mean difference was only 10 mm, which is acceptable for navigating perforator flap operations. Pig backs are triangular in shape; therefore, we were unable to place markers on the contralateral side. Thus, for clinical applications of the device, we should determine the ideal marker locations.
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Affiliation(s)
- Hisato Konoeda
- Plasic and Reconstructive Surgery Division, Tokyo Joshi Ika Daigaku Byoin, Shinjuku-ku, Japan
| | - Miyuki Uematsu
- Division of Medical Devices, National Institute of Health Sciences, Kawasaki, Japan
| | - Nie Jumxiao
- Information Science and Technology Division, The University of Tokyo, Bunkyo-ku, Japan
| | - Ken Masamune
- Advanced Biomedical Engineering and Science Division, Tokyo Joshi Ika Daigaku, Shinjuku-ku, Japan
| | - Hiroyuki Sakurai
- Plasic and Reconstructive Surgery Division, Tokyo Joshi Ika Daigaku Byoin, Shinjuku-ku, Japan
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Waked K, Mespreuve M, De Ranter J, Collard B, Hahn S, Hendrickx B. Visualising the individual arterial anatomy of the face through augmented reality - a useful and accurate tool during dermal filler injections. Aesthet Surg J Open Forum 2022; 4:ojac012. [PMID: 35517577 PMCID: PMC9067448 DOI: 10.1093/asjof/ojac012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The arterial anatomy of the face is extremely variable. Despite numerous cadaver dissections and anatomical descriptions, the exact location of the superficial facial arteries remains unpredictable. This ignorance is a determining factor in the pathophysiology of intravascular filler injections, potentially causing skin necrosis and blindness. Objectives The main objective of this study is to evaluate the accuracy of an augmented reality (AR) application that visualizes the individual arterial anatomy of the face. Methods A workflow was developed during which a magnetic resonance angiography (MRA) mapped the superficial arteries of the face. The images were further processed into an AR image that was visualized on the patient’s face using a specifically designed smartphone application. The accuracy of the AR image and the position of each individual artery were analyzed using duplex ultrasound (US). Results A total of 216 facial arteries were visualized in 20 patients. The superficial temporal (100%), supratrochlear (92.5%), facial (75%), and angular (82.5%) arteries were visualized the most. The inferior labial (17.5%), dorsal nasal (22.5%), and supraorbital (42.5%) arteries were the most difficult to visualize through MRA. The average deviation between the artery visible on the AR image and the location assessed by US was 0.30 mm (standard deviation = +/− 0.66 mm). There were no complications reported. Conclusions The combination of a risk-free MRA to map the individual arteries of the face and the processing into an AR image may be considered as a useful and accurate tool during dermal filler injections to potentially minimize the risk of intravascular filler injections.
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Affiliation(s)
- Karl Waked
- Department of Plastic and Reconstructive Surgery, University Hospital Brussel, Brussels, Belgium
| | - Marc Mespreuve
- Department of Medical Imaging, University Hospital Ghent, Ghent, Belgium
| | - Joris De Ranter
- Department of Plastic and Reconstructive Surgery, University Hospital Leuven, Leuven, Belgium
| | - Barbara Collard
- Department of Medical Imaging, AZ Zeno Hospital, Knokke-Heist, Belgium
| | - Stephan Hahn
- Université Libre de Bruxelles, Brussels, Belgium
| | - Benoit Hendrickx
- Department of Plastic and Reconstructive Surgery, University Hospital Brussel, Brussels, Belgium
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