The state of virtual surgical planning in maxillary Reconstruction: A systematic review

Precise maxillofacial soft tissue reconstruction: A combination of cone beam computed tomography and 3dMD photogrammetry system

Introduction

The reconstruction of both extra- and intra-oral soft tissue defects, particularly in restoring the morphology of the lip and the corners of the mouth, has posed a significant challenge for surgeons. Inappropriate methods often lead to maxillofacial deformity which then causes psychological and functional problems. This study aimed to address the challenge of reconstructing extensive and complex maxillofacial soft tissue defects, mainly focusing on the lip, the corners of the mouth, and the surrounding areas.

Materials and methods

We developed a reconstruction approach by combining the 3dMDface System (3dMD) with the cone beam computed tomography (CBCT). Firstly, with the extra-oral incision line, we evaluated the shape and the size of the extra-oral defect with 3dMD digitally. Then we used the corresponding maxillary and mandible tooth positions to record the intra-oral defect, which was then converted to digital images by combining 3dMD and CBCT. The islands of the anterolateral thigh perforator flap were then designed after the locations of the perforators were detected with Doppler ultrasonography.

Results

A clinical case diagnosed as dermatofibrosarcoma protuberans was presented to illustrate the approach. The patient's tumor resection and the size of multiple defects were measured and simulated via the virtual surgery system. A three-island perforator flap from the descending branch of the lateral femoral circumflex artery was designed accurately. Two weeks postoperatively, the flap was healed as anticipated and the patient was satisfied with the profile.

Conclusion

The combination of the 3dMD and CBCT technologies improves the accuracy and fitness of extra- and intra-oral soft tissue reconstruction.

Evaluating the benefit of virtual surgical planning on bony union rates in head and neck reconstructive surgery

OBJECTIVES

Virtual surgical planning (VSP) has gained acceptance because of its benefits in obtaining adequate resection, achieving cephalometric accuracy, and reducing operative time. The aim of this study is to compare the rate of union between VSP and free-hand surgery (FHS), identify predictors of non-union and evaluate the difference in operative time.

METHODS

Post-operative CT were retrospectively reviewed for 123 patients who underwent maxillary or mandibular reconstruction between 2014 and 2021 using either VSP or FHS. Each apposition was graded as complete, partial or non-union. The rate of union, risk difference and inter-rater reliability were calculated. The difference in operative time was assessed. Predictors of non-union were identified using logistic regression.

RESULTS

A total of 326 appositions were graded (VSP n = 150; FHS n = 176). The rates of complete and partial union were higher with VSP than FHS (74.7% vs. 65.3%; 18% vs. 15.9%, respectively, p = 0.01). Non-union was found at a higher rate with FHS than with VSP (18.7% vs. 7.3%). The non-union risk difference was 11.4. FHS, major complications and apposition at the native bone were predictors of non-union (OR 2.9, p = 0.02; OR 3.4, p = 0.01; OR 2.5, p = 0.05, respectively). The mean surgical time was shorter with VSP than with FHS (265.3 vs. 381.5 min, p < 0.001). The inter-rater agreement was high (k = 0.85; ICC = 0.86).

CONCLUSION

VSP demonstrated significantly higher bony union rates and shorter operative time. FHS, development of major complications and apposition with native bone correlated with non-union.

Multiple Buttresses Reconstruction of Maxilla with Fibular Flap Using Computer-aided Design/Computer-aided Manufacturing after Maxillectomy

Background

The maxilla comprises horizontal and vertical buttresses, each with specific functions, supporting various organs, such as the eyes, nose, and oral cavity. Notably, they combine to form a three-dimensional structure, which enables the buttresses to provide their inherent support strength. However, reconstructing the maxilla after maxillectomy by assembling new buttresses is challenging. We successfully reconstructed all the buttresses crucial for facial appearance and dental rehabilitation using a vascularized fibular flap.

Methods

Four patients underwent maxillary buttress reconstruction with a fibular flap after total or subtotal maxillectomy. We used computer-aided design/computer-aided manufacturing digital technology to osteotomize the fibula into multiple segments and assemble them to reconstruct the maxillary buttresses. Each buttress was assembled based on a preoperative simulation.

Results

All patients underwent immediate one-stage maxillary reconstruction. They had good maxillary buttress alignment and acquired good facial appearance, eye position, nasal airway, and prosthetically suitable maxillary alveolus ridge.

Conclusions

The combination of computer-aided design/computer-aided manufacturing digital technology and surgical techniques has enabled novel maxillary reconstruction, providing great hope to patients experiencing facial disfigurement and loss of function after maxillectomy.

From bench to bedside - current clinical and translational challenges in fibula free flap reconstruction

Fibula free flaps (FFF) represent a working horse for different reconstructive scenarios in facial surgery. While FFF were initially established for mandible reconstruction, advancements in planning for microsurgical techniques have paved the way toward a broader spectrum of indications, including maxillary defects. Essential factors to improve patient outcomes following FFF include minimal donor site morbidity, adequate bone length, and dual blood supply. Yet, persisting clinical and translational challenges hamper the effectiveness of FFF. In the preoperative phase, virtual surgical planning and artificial intelligence tools carry untapped potential, while the intraoperative role of individualized surgical templates and bioprinted prostheses remains to be summarized. Further, the integration of novel flap monitoring technologies into postoperative patient management has been subject to translational and clinical research efforts. Overall, there is a paucity of studies condensing the body of knowledge on emerging technologies and techniques in FFF surgery. Herein, we aim to review current challenges and solution possibilities in FFF. This line of research may serve as a pocket guide on cutting-edge developments and facilitate future targeted research in FFF.

History, Innovation, Pearls, and Pitfalls in Complex Midface Reconstruction

Midface reconstruction in head and neck cancer or individuals with extensive trauma to the face has evolved significantly over the past few decades with the introduction of free flap reconstruction and virtual surgical planning enabling surgeons to obtain optimal cosmetic and functional outcomes. Traditional methods such as the use of obturators or local flaps still have a role in select situations, but complex defects have been replaced by the advent of microvascular free tissue transfer and virtual planning, which can commonly provide a single-stage reconstruction of the midface with excellent aesthetic and functional results. This article provides an overview of the history and evolution of midface reconstruction, a discussion of how to integrate virtual surgical planning into a surgical practice, an example of a complex midface reconstruction case, and pearls and pitfalls that have been experienced by an experienced reconstructive team.

Oral Cavity Reconstruction

This summary provides a concise overview of oral cavity reconstruction to optimize functional outcomes in the modern era. Soft tissue and osseous reconstruction options for a wide range of oral cavity sites including lip, oral tongue, floor of mouth, buccal, hard palate, and composite oromandibular resections are reviewed. The appropriate applications of primary closure, secondary intention, skin grafts, and dermal substitute grafts are included. Anatomic considerations, indications, contraindications, and complications of local, regional, and free flaps in oral cavity reconstruction are discussed. Specific defects and the appropriate options for reconstruction of those defects are delineated.

Virtual surgical planning for maxillary reconstruction with the scapular free flap: An evaluation of a simple cutting guide design

BACKGROUND

The study's objective is to assess the feasibility and utility of VSP for maxillary reconstruction with the scapular free flap.

METHODS

An open-source VSP platform was used to create the reconstruction models and simple guides. Clinical, operative, and postoperative data were collected.

RESULTS

Ten patients in the VSP cohort and 18 in the non-VSP control cohort were included in the study. There was a significant reduction in operative time (256.0 ± 69.4 vs. 448.1 ± 108.2 min, p < 0.01), tracheotomy rate (20% vs. 72%, p < 0.01), increased two-team utilization rate (80% vs. 0%, p < 0.01) and better reconstructive accuracy (7.5 ± 3.4 vs. 11.7 ± 7.6 mm, p = 0.048) for the VSP cohort.

CONCLUSIONS

Maxillary reconstruction planned with an in-house open-source VSP platform and accompanied simple guides can facilitate a two-team approach, reduce operative time, and improve structural accuracy. This open-source technology has great potential to be readily applied in other institutions to improve efficiency and outcomes.