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Morrison EJ, Matros E. Modern Oncologic Maxillary Reconstruction. Plast Reconstr Surg 2024; 154:601e-618e. [PMID: 39196869 DOI: 10.1097/prs.0000000000011476] [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: 08/30/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Have a broad understanding of the oncological principles relating to cancers involving the maxilla. (2) Define anatomically the various types of maxillectomy defects and their associated morbidity. (3) Understand the goals and principles of maxillary reconstruction. (4) Demonstrate an understanding of the strengths, limitations, and alternative reconstructive options for the various types of maxillectomy defects. SUMMARY Reconstruction of the maxilla following cancer resection has evolved over the past decade. Underpinned by advances in virtual surgery technology and an increased focus on dental rehabilitation, more sophisticated workflows using free bone flaps have become more commonplace. There are few reconstructions anywhere in the body that require the restoration of similarly intricate bone and soft-tissue relations with implications for both form and function, like the maxilla. Success demands careful anatomical definition of the defect, an understanding of the goals and principles of reconstruction, and the understanding of relative strengths and limitations of the various reconstructive options. Equally, as no one technique is without shortcomings and maxillary surgery can be associated with a significant complication profile, it is just as important to match the patient and oncologic context to the reconstruction. This article is intended to provide the reader with a broad overview of these core factors.
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Affiliation(s)
- Edwin J Morrison
- From the Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering
| | - Evan Matros
- From the Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering
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Lindhardt JL, Kiil BJ, Jakobsen AM, Buhl J, Krag AE. Implementation of In-house Computer-aided Design and Manufacturing for Accelerated Free Fibula Flap Reconstruction of Mandibular Defects in Cancer Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6108. [PMID: 39206213 PMCID: PMC11350334 DOI: 10.1097/gox.0000000000006108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/05/2024] [Indexed: 09/04/2024]
Abstract
Background Computer-aided design and manufacturing (CAD/CAM) is widely adopted for optimizing microsurgical reconstruction of mandibular defects. However, commercial solutions are hampered by costs and lengthy lead times, with the latter being problematic in cancer surgery. This study aimed to investigate the efficiency of an in-house CAD/CAM service for expeditious planning and execution of free fibula mandibular reconstruction in head and neck cancer patients. Methods This retrospective cohort study compared cancer patients undergoing segmental mandibulectomy and immediate free fibula flap reconstruction treated before and after implementation of in-house CAD/CAM. The primary endpoint was treatment delay from preoperative consultation to surgery. Cases in the two groups were matched on the number of fibula segments required for mandibular reconstruction. The control group underwent segmental mandibulectomy and fibula flap reconstruction by "freehand." The CAD/CAM group underwent preoperative virtual surgical planning and CAD/CAM of intraoperative cutting guides for the mandibulectomy and fibula osteotomies. Outcomes were compared with the unpaired t test or Wilcoxon rank-sum test. Results Sixteen patients were included in both groups. Treatment delay did not increase after implementation of in-house CAD/CAM with a median 6 (range 6-20) days wait in the CAD/CAM group and 8 (6-20) days wait in the control group (P = 0.48). Utilization of CAD/CAM significantly reduced fibula flap ischemia time with a mean of 18.4 [95% confidence interval 2.8; 33.9] minutes (P = 0.022). Conclusions In-house CAD/CAM was implemented for free fibula flap mandibular reconstruction in head and neck cancer patients without causing treatment delay. Furthermore, CAD/CAM reduced fibula flap ischemia time.
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Affiliation(s)
| | - Birgitte J. Kiil
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jytte Buhl
- Department of Maxillofacial Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Andreas E. Krag
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Hu KG, Aral A, Rancu A, Alperovich M. Computerized Surgical Planning for Mandibular Distraction Osteogenesis. Semin Plast Surg 2024; 38:234-241. [PMID: 39118864 PMCID: PMC11305829 DOI: 10.1055/s-0044-1786757] [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: 08/10/2024]
Abstract
Mandibular distraction osteogenesis is a technically challenging procedure due to complex mandibular anatomy, especially in the treatment of Pierre-Robin Sequence due to variable bone thickness in the infant mandible and the presence of tooth buds. Computerized surgical planning (CSP) simplifies the procedure by preoperatively visualizing critical structures, producing cutting guides, and planning distractor placement. This paper describes the process of using CSP to plan mandibular distraction osteogenesis, including discussion of recent advances in the use of custom distractors.
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Affiliation(s)
- Kevin G. Hu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ali Aral
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Albert Rancu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael Alperovich
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Gardiner L, Smith B, Kubik M, Solari M, Smith K, de Almeida JR, Sridharan S. Long-term outcomes in virtual surgical planning for mandibular reconstruction: A cost-effectiveness analysis. Microsurgery 2024; 44:e31206. [PMID: 38943374 DOI: 10.1002/micr.31206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 05/02/2024] [Accepted: 06/07/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE This study is an economic evaluation comparing virtual surgical planning (VSP) utilization to free hand mandibular reconstruction (FHR) for advanced oral cavity cancer, for which the cost effectiveness remains poorly understood. The proposed clinical benefits of VSP must be weighed against the additional upfront costs. METHODS A Markov decision analysis model was created for VSP and FHR based on literature review and institutional data over a 35-year time horizon. Model parameters were derived and averaged from systematic review and institutional experience. VSP cost and surgical time saving was incorporated. We accounted for long-term risks including cancer recurrence and hardware failure/exposure. We calculated cost in US dollars and effectiveness in quality-adjusted-life-years (QALYs). A health care perspective was adopted, discounting costs and effectiveness at 3%/year. Deterministic and probabilistic sensitivity analyses tested model robustness. RESULTS In the base case scenario, total VSP strategy cost was $49,498 with 8.37 QALYs gained while FHR cost was $42,478 with 8.27 QALY gained. An incremental cost-effectiveness ratio (ICER), or the difference in cost/difference in effectiveness, for VSP was calculated at $68,382/QALY gained. VSP strategy favorability was sensitive to variations of patient age at diagnosis and institutional VSP cost with one-way sensitivity analysis. VSP was less economically favorable for patients >75.5 years of age or for institutional VSP costs >$10,745. In a probabilistic sensitivity analysis, 55% of iterations demonstrated an ICER value below a $100,000/QALY threshold. CONCLUSIONS/RELEVANCE VSP is economically favorable compared to FHR in patients requiring mandibular reconstruction for advanced oral cancer, but these results are sensitive to the patient's age at diagnosis and the institutional VSP cost. Our results do not suggest if one "should or should not" use VSP, rather, emphasizes the need for patient selection regarding which patients would most benefit from VSP when evaluating quality of life and long-term complications. Further studies are necessary to demonstrate improved long-term risk for hardware failure/exposure in VSP compared to FHR.
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Affiliation(s)
- Lauren Gardiner
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brandon Smith
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark Kubik
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mario Solari
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kenneth Smith
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John R de Almeida
- Department of Otolaryngology-Head Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Speed OE, Rickels KL, Farsi S, Merrill T, Gardner JR, King D, Sunde J, Vural E, Moreno MA. Virtual surgical planning for mandibular reconstruction in an abbreviated admission pathway. Am J Otolaryngol 2024; 45:104141. [PMID: 38194889 DOI: 10.1016/j.amjoto.2023.104141] [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: 09/28/2023] [Accepted: 12/03/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Virtual Surgical Planning (VSP) creates individualized surgical plans for free flap reconstruction of mandibular defects. Prior studies indicate that VSP can offer cost benefits due to reduced operative time and length of stay (LOS). We assessed the impact of VSP in the context of a validated postoperative abbreviated LOS clinical pathway. METHODS This study assessed patients undergoing VSP vs conventional fibular free flap reconstruction for mandibular defects (12/2015-10/2020) and their operative time, ischemia time, and LOS were evaluated. RESULTS Forty-four patients underwent VSP reconstruction, while 52 patients underwent conventional reconstruction for mandibular defects. VSP was associated with significantly lower total operative time (6 h and 57 mins vs 7 h and 54 mins, p = 0.011), but not length of stay or ischemia time. Total OR time was significantly increased with increasing number of segments needed in both the VSP group (p = 0.002) and the conventional group (p = 0.015). CONCLUSION Shorter operative times and LOS have been attributed to the use of VSP in free tissue transfers. It is argued that these reductions offset the added cost of VSP. Our study indicates that there is no cost benefit for VSP utilization due to a significantly reduced operative time with no impact on length of admission in an abbreviated admission clinical pathway following free tissue transfer.
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Affiliation(s)
- Olivia E Speed
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - Kaersti L Rickels
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - Soroush Farsi
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - Tyler Merrill
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - J Reed Gardner
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - Deanne King
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - Jumin Sunde
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - Emre Vural
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America
| | - Mauricio A Moreno
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences. Little Rock, AR, United States of America.
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Almeida MN, Alper DP, Williams MCG, Ihnat JMH, Parikh N, Diluna M, Alperovich M. Virtual Surgical Planning in Craniosynostosis Reduces Operative Time and Length of Stay for Cranial Vault Remodeling. J Craniofac Surg 2023; 34:1931-1933. [PMID: 37643076 DOI: 10.1097/scs.0000000000009697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/27/2023] [Indexed: 08/31/2023] Open
Abstract
Cranial vault remodeling (CVR) with and without frontal orbital advancement remodels the skull in craniosynostosis. Virtual surgical planning (VSP) for preoperative planning has been previously shown to be effective in CVR. In this study, the authors aimed to evaluate the impact of VSP on operative and perioperative efficiency for craniosynostosis surgery. A retrospective chart review was conducted of patients with craniosynostosis who underwent CVR. Patient demographics, perioperative variables, use of VSP, and complications were obtained. Perioperative variables collected include operative time and length of stay. An independent t test was used to compare variables from patients who had surgery with VSP and patients who did not. Records were available for 126 patients with craniosynostosis who underwent CVR of whom 79 (62.7%) utilized VSP. There was no difference in average age at surgery (9.3±5.7 mo versus 13.2±31.1 mo, P =0.39). Surgeries planned using VSP demonstrated a decreased operative time of 1.3 hours (3.7±1.1 versus 5.0±1.1 h, P <0.001) and a shorter length of stay (3.9±1.3 versus 4.6±1.7 d, P =0.01). There were no differences in complication rates of dehiscence, infection, returns to the operating room, or 30-day readmission. These trends were similar among patients who underwent fronto-orbital advancement in addition to CVR. Virtual surgical planning was associated with decreased operative time and length of stay for patients with craniosynostosis and comparable complication rates. Virtual surgical planning is an effective tool for reducing anesthetic exposure time.
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Affiliation(s)
- Mariana N Almeida
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT
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Desai DD, Alwani M, Sheen D, Narayanan A, Gordin E. The Use of Patient-Specific Orbital Reconstruction Implants During Maxillectomy Reconstruction. Facial Plast Surg Aesthet Med 2023; 25:403-408. [PMID: 36856488 DOI: 10.1089/fpsam.2022.0201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Background: Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity. Study Objective: To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI). Design Type: Case series. Materials and Methods: Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications. Results: The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients. Conclusion: PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.
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Affiliation(s)
- Dipan D Desai
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mohamedkazim Alwani
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Derek Sheen
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ajay Narayanan
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Eli Gordin
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
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Kakarala K, Mifsud M, Dziegielewski P. Improving Quality and Value in Head and Neck Reconstruction. Otolaryngol Clin North Am 2023; 56:853-858. [PMID: 37380327 DOI: 10.1016/j.otc.2023.04.019] [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: 06/30/2023]
Abstract
Multiple advances in surgical techniques, technology, and perioperative patient care have revolutionized head and neck reconstruction over the last 40 years. Concurrent with these advances, health systems, patients, and payers have become increasingly focused on value and quality, owing in part to rapidly increasing health care costs. However, there is no consensus on how to define value and quality in the realm of head and neck reconstruction. This review focuses on the past, present, and future of quality improvement efforts in head and neck reconstruction.
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Affiliation(s)
- Kiran Kakarala
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Matthew Mifsud
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida School of Medicine, 13330 USF Laurel Drive, Tampa, FL 33612, USA
| | - Peter Dziegielewski
- Department of Otolaryngology-Head and Neck Surgery, University of Florida School of Medicine, 1600 Southwest Archer Road, D1-121, Gainesville, FL 32608, USA
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Kurlander DE, Garvey PB, Largo RD, Yu P, Chang EI, Hanasono MM, Mericli AF. The Cost Utility of Virtual Surgical Planning and Computer-Assisted Design/Computer-Assisted Manufacturing in Mandible Reconstruction Using the Free Fibula Osteocutaneous Flap. J Reconstr Microsurg 2023; 39:221-230. [PMID: 35988577 DOI: 10.1055/s-0042-1755260] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND The use of virtual surgical planning and computer-assisted design and computer-assisted manufacturing (CAD/CAM) has become widespread for mandible reconstruction with the free fibula flap. However, the cost utility of this technology remains unknown. METHODS The authors used a decision tree model to evaluate the cost utility, from the perspective of a hospital or insurer, of mandible reconstruction using CAD/CAM relative to the conventional (non-CAD/CAM) technique for the free fibula flap. Health state probabilities were obtained from a published meta-analysis. Costs were estimated using 2018 Centers for Medicare and Medicaid Services data. Overall expected cost and quality-adjusted life-years (QALYs) were assessed using a Monte Carlo simulation and sensitivity analyses. Cost effectiveness was defined as an incremental cost utility ratio (ICUR) less than the empirically accepted willingness-to-pay value of $50,000 per QALY. RESULTS Although CAD/CAM reconstruction had a higher expected cost compared with the conventional technique ($36,487 vs. $26,086), the expected QALYs were higher (17.25 vs. 16.93), resulting in an ICUR = $32,503/QALY; therefore, the use of CAD/CAM in free fibula flap mandible reconstruction was cost-effective relative to conventional technique. Monte Carlo sensitivity analysis confirmed CAD/CAM's superior cost utility, demonstrating that it was the preferred and more cost-effective option in the majority of simulations. Sensitivity analyses also illustrated that CAD/CAM remains cost effective at an amount less than $42,903 or flap loss rate less than 4.5%. CONCLUSION This cost utility analysis suggests that mandible reconstruction with the free fibula osteocutaneous flap using CAD/CAM is more cost effective than the conventional technique.
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Affiliation(s)
- David E Kurlander
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patrick B Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rene D Largo
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexander F Mericli
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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The state of virtual surgical planning in maxillary Reconstruction: A systematic review. Oral Oncol 2022; 133:106058. [PMID: 35952582 DOI: 10.1016/j.oraloncology.2022.106058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/12/2022] [Accepted: 08/01/2022] [Indexed: 11/20/2022]
Abstract
Virtual surgical planning (VSP) and computer aided design utilization in head and neck reconstruction has become increasingly popular within the discipline. Advocates of the technology over traditional free hand surgery cite benefits including improved intraoperative efficiencies and postoperative outcomes that have been demonstrated during mandibular reconstruction. More recently, VSP for maxillary and mid facial reconstruction, generally considered more complex than their mandibular counterparts, have been applied with the hopes of similar benefits. However, our literature search revealed no large-scale randomized control trial substantiating these benefits. As such, the aim of this review was to synthesize the existing research on utilization of VSP in the context of maxillary reconstruction. Three databases were systematically searched for articles pertaining to maxillary reconstruction for oncologic, traumatic, or osteoradionecrosis indications. Four hundred and fourteen unique articles were reviewed by two independent reviewers ultimately revealing sixteen studies appropriate for qualitative synthesis including 142 patients. Results of our studies reveal the extreme heterogenicity of application of this technology under the label of virtual surgical planning. Outcome reporting methods were grossly inconsistent amongst all the articles resulting in inability to appropriately synthesize data quantitatively for a meta-analysis. Overall, there was no standard of reporting outcomes of maxillary reconstruction, and no randomized trials comparing virtual surgical planning versus freehand surgery and therefore there is insufficient data to objectively prove purported benefits. To facilitate future comparative studies, a minimal standard of reporting for maxillary VSP is presented and the need for a randomized control trial is highlighted.
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Tran KL, Mong ML, Durham JS, Prisman E. Benefits of Patient-Specific Reconstruction Plates in Mandibular Reconstruction Surgical Simulation and Resident Education. J Clin Med 2022; 11:jcm11185306. [PMID: 36142953 PMCID: PMC9501640 DOI: 10.3390/jcm11185306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/21/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022] Open
Abstract
Poorly contoured mandibular reconstruction plates are associated with postoperative complications. Recently, a technique emerged whereby preoperative patient-specific reconstructive plates (PSRP) are developed in the hopes of eliminating errors in the plate-bending process. This study’s objective is to determine if reconstructions performed with PSRP are more accurate than manually contoured plates. Ten Otolaryngology residents each performed two ex vivo mandibular reconstructions, first using a PSRP followed by a manually contoured plate. Reconstruction time, CT scans, and accuracy measurements were collected. Paired Student’s t-test was performed. There was a significant difference between reconstructions with PSRP and manually contoured plates in: plate-mandible distance (0.39 ± 0.21 vs. 0.75 ± 0.31 mm, p = 0.0128), inter-fibular segment gap (0.90 ± 0.32 vs. 2.24 ± 1.03 mm, p = 0.0095), mandible-fibula gap (1.02 ± 0.39 vs. 2.87 ± 2.38 mm, p = 0.0260), average reconstruction deviation (1.11 ± 0.32 vs. 1.67 ± 0.47 mm, p = 0.0228), mandibular angle width difference (5.13 ± 4.32 vs. 11.79 ± 4.27 mm, p = 0.0221), and reconstruction time (16.67 ± 4.18 vs. 33.78 ± 8.45 min, p = 0.0006). Lower plate-mandible distance has been demonstrated to correlate with decreased plate extrusion rates. Similarly, improved bony apposition promotes bony union. PSRP appears to provide a more accurate scaffold to guide the surgeons in assembling donor bone segments, which could potentially improve patient outcome and reduce surgical time. Additionally, in-house PSRP can serve as a low-cost surgical simulation tool for resident education.
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Nyirjesy SC, Heller M, von Windheim N, Gingras A, Kang SY, Ozer E, Agrawal A, Old MO, Seim NB, Carrau RL, Rocco JW, VanKoevering KK. The role of computer aided design/computer assisted manufacturing (CAD/CAM) and 3- dimensional printing in head and neck oncologic surgery: A review and future directions. Oral Oncol 2022; 132:105976. [PMID: 35809506 DOI: 10.1016/j.oraloncology.2022.105976] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/17/2022] [Indexed: 01/12/2023]
Abstract
Microvascular free flap reconstruction has remained the standard of care in reconstruction of large tissue defects following ablative head and neck oncologic surgery, especially for bony structures. Computer aided design/computer assisted manufacturing (CAD/CAM) and 3-dimensionally (3D) printed models and devices offer novel solutions for reconstruction of bony defects. Conventional free hand techniques have been enhanced using 3D printed anatomic models for reference and pre-bending of titanium reconstructive plates, which has dramatically improved intraoperative and microvascular ischemia times. Improvements led to current state of the art uses which include full virtual planning (VP), 3D printed osteotomy guides, and patient specific reconstructive plates, with advanced options incorporating dental rehabilitation and titanium bone replacements into the primary surgical plan through use of these tools. Limitations such as high costs and delays in device manufacturing may be mitigated with in house software and workflows. Future innovations still in development include printing custom prosthetics, 'bioprinting' of tissue engineered scaffolds, integration of therapeutic implants, and other possibilities as this technology continues to rapidly advance. This review summarizes the literature and serves as a summary guide to the historic, current, advanced, and future possibilities of 3D printing within head and neck oncologic surgery and bony reconstruction. This review serves as a summary guide to the historic, current, advanced, and future roles of CAD/CAM and 3D printing within the field of head and neck oncologic surgery and bony reconstruction.
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Affiliation(s)
- Sarah C Nyirjesy
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Margaret Heller
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Natalia von Windheim
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Amelia Gingras
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Stephen Y Kang
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Enver Ozer
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Amit Agrawal
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Matthew O Old
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Nolan B Seim
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Ricardo L Carrau
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - James W Rocco
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States
| | - Kyle K VanKoevering
- Department of Otolaryngology- Head and Neck Surgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43210, United States.
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Alnemri A, Philips R, Sussman S, Xu V, Givens A, Patel A, Swendseid B, Agarwal A, Keith S, Shimada A, Selman Y, Cognetti DM, Heffelfinger R, Goldman R, Luginbuhl AJ, Wax MK, Sweeny L, Curry JM. Analysis of cost and outcomes in bony versus soft tissue midface free flap reconstruction. Head Neck 2022; 44:1896-1908. [PMID: 35665975 DOI: 10.1002/hed.27112] [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: 09/26/2021] [Revised: 05/01/2022] [Accepted: 05/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Outcomes and cost of soft tissue versus bony midface free flap reconstruction (MR) with and without virtual surgical planning (VSP) were evaluated. METHODS Retrospective review of MR including ischemic time (IT), operative duration (OD), length of stay (LOS), and total cost (TC). Eighty-one soft tissue and 76 bony MR (VSP = 23) were reviewed. RESULTS Bony MR was used for higher complexity defects (p = 0.003) and was associated with higher IT (p < 0.001), OD (p < 0.001), LOS (p = 0.032), and TC (p < 0.001). VSP was associated with a mean 111.2 ± 37.9 minute reduction in OD (p = 0.004) compared to non-VSP bony flaps. VSP was associated with higher itemized cost, but no increase in TC (p = 0.327). CONCLUSIONS Bony MR was used for higher complexity MR and was associated with increased TC, LOS, OD, and IT. VSP shortened OD with no significant increase in TC.
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Affiliation(s)
- Angela Alnemri
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ramez Philips
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sarah Sussman
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vivian Xu
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alyssa Givens
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Anjali Patel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian Swendseid
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Aarti Agarwal
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Scott Keith
- Division of Biostatistics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ayako Shimada
- Division of Biostatistics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yamil Selman
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David M Cognetti
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard Goldman
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam J Luginbuhl
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark K Wax
- Department of Otolaryngology - Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Larissa Sweeny
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Joseph M Curry
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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GIOVACCHINI F, MONARCHI G, MITRO V, GILLI M, BENSI C, TULLIO A. Maxilla reconstruction using a free fibula flap and virtual planning. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05242-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Miles BA, McMullen CP, Sweeny L, Zenga J, Li R, Divi V, Jackson R, Patel UA, Richmon JD. Practice patterns of virtual surgical planning: Survey of the reconstructive section of the American Head and Neck Society. Am J Otolaryngol 2022; 43:103225. [PMID: 34571439 DOI: 10.1016/j.amjoto.2021.103225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/06/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE Virtual surgical planning (VSP), with custom made implants and guides represents a recent major advance. Nonetheless, knowledge related to practice patterns is limited. The purpose of this study was to provide data from the AHNS Reconstruction Section related to practice patterns, perceived value of VSP, as well as elucidate specific situations which represent high value for the application of VSP. MATERIALS AND METHODS A multi-center web-based survey consisting of 30 questions regarding practice patterns related to VSP practices delivered via email to 203 members of the AHNS Reconstructive Surgery Section at institutions across North America. RESULTS There was a 34% response rate (70/203). A majority of the respondents (96%) used VSP in approximately 50% of their mandibular reconstruction cases, and in 42% of maxillary cases. 46% reported using patient specific implants >75% of cases. Respondents estimated that ~17% of patients received dental implant reconstruction. The majority of respondents (71.0%) did not know the cost of VSP at their institution. The remaining respondents indicated the average cost was $6680 per case. VSP was felt to be necessary as a teaching tool by 55.9%. CONCLUSIONS Our results demonstrate that a majority of respondents frequently utilize VSP in their practice for head and neck reconstruction. Complex, multi-unit reconstructions were felt to offer the greatest value when utilizing VSP. Future work should focus on increasing the rates of dental implant reconstruction in this population, optimizing value of VSP with careful case selection, and understanding the educational value and costs of these platforms.
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Ritschl LM, Kilbertus P, Grill FD, Schwarz M, Weitz J, Nieberler M, Wolff KD, Fichter AM. In-House, Open-Source 3D-Software-Based, CAD/CAM-Planned Mandibular Reconstructions in 20 Consecutive Free Fibula Flap Cases: An Explorative Cross-Sectional Study With Three-Dimensional Performance Analysis. Front Oncol 2021; 11:731336. [PMID: 34631563 PMCID: PMC8498593 DOI: 10.3389/fonc.2021.731336] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022] Open
Abstract
Background Mandibular reconstruction is conventionally performed freehand, CAD/CAM-assisted, or by using partially adjustable resection aids. CAD/CAM-assisted reconstructions are usually done in cooperation with osteosynthesis manufacturers, which entails additional costs and longer lead time. The purpose of this study is to analyze an in-house, open-source software-based solution for virtual planning. Methods and Materials All consecutive cases between January 2019 and April 2021 that underwent in-house, software-based (Blender) mandibular reconstruction with a free fibula flap (FFF) were included in this cross-sectional study. The pre- and postoperative Digital Imaging and Com munications in Medicine (DICOM) data were converted to standard tessellation language (STL) files. In addition to documenting general information (sex, age, indication for surgery, extent of resection, number of segments, duration of surgery, and ischemia time), conventional measurements and three-dimensional analysis methods (root mean square error [RMSE], mean surface distance [MSD], and Hausdorff distance [HD]) were used. Results Twenty consecutive cases were enrolled. Three-dimensional analysis of preoperative and virtually planned neomandibula models was associated with a median RMSE of 1.4 (0.4–7.2), MSD of 0.3 (-0.1–2.9), and HD of 0.7 (0.1–3.1). Three-dimensional comparison of preoperative and postoperative models showed a median RMSE of 2.2 (1.5–11.1), MSD of 0.5 (-0.6–6.1), and HD of 1.5 (1.1–6.5) and the differences were significantly different for RMSE (p < 0.001) and HD (p < 0.001). The difference was not significantly different for MSD (p = 0.554). Three-dimensional analysis of virtual and postoperative models had a median RMSE of 2.3 (1.3–10.7), MSD of -0.1 (-1.0–5.6), and HD of 1.7 (0.1–5.9). Conclusions Open-source software-based in-house planning is a feasible, inexpensive, and fast method that enables accurate reconstructions. Additionally, it is excellent for teaching purposes.
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Affiliation(s)
- Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Paul Kilbertus
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Florian D Grill
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Matthias Schwarz
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Jochen Weitz
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Department of Oral and Maxillofacial Surgery, Josefinum, Augsburg and Private Practice Oral and Maxillofacial Surgery im Pferseepark, Augsburg, Germany
| | - Markus Nieberler
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Andreas M Fichter
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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17
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A Novel Approach to Virtual Surgical Planning for Mandibular and Midfacial Reconstruction With a Fibula Free Flap. J Craniofac Surg 2021; 33:759-763. [PMID: 34560742 DOI: 10.1097/scs.0000000000008169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The fibula free flap is a major workhorse in facial reconstruction. To decrease operative times, virtual surgical planning (VSP) has been implemented. Traditional VSP is costly and may delay operative planning. In this study, the authors present a novel algorithm using readily accessible software packages to perform VSP in a manner that is quick and cost-effective. METHODS A 6-part survey was administered to physicians with prior training in facial reconstruction. Fourteen physicians participated regarding outcomes on 10 patients who underwent mandibular or midfacial fibula free flap reconstruction. Participants were asked to match the true postoperative and VSP models and rate the similarity of the models using the Likert scale (0-10). The goal was to determine whether the VSP models accurately depicted the actual reconstruction, and whether they would use VSP in future clinical practice. RESULTS The physicians surveyed were able to match the models correctly 93.6% of the time. The mean score for the similarity between virtual and actual models ranged between 7.60 and 8.80. Most participants (90.9%) who answered stated they would use our VSP algorithm if they were trained in the protocol. CONCLUSIONS AND RELEVANCE Virtual surgical planning models were created utilizing our novel algorithm. Participants matched the preoperative VSP plan with the postoperative model most of the time and rated the similarity well. Participants in our study are interested in learning more about physician performed VSP. The authors believe this model may be financially and clinically relevant and serve as an excellent educational tool.
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18
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Virtual Surgical Planning for Oncologic Mandibular and Maxillary Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3672. [PMID: 34548995 PMCID: PMC8448079 DOI: 10.1097/gox.0000000000003672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 05/14/2021] [Indexed: 11/25/2022]
Abstract
Virtual surgical planning (VSP) with computer-aided design and computer-aided modeling (CAD/CAM) enables the opportunity to provide personalized medicine in complex head and neck reconstruction. This innovative technology allows ablative and reconstructive surgeons to virtually create and manipulate three-dimensional anatomic models to plan both the resection and reconstruction of complicated maxillofacial defects. Studies demonstrate improvements in preoperative planning, operative efficiency and accuracy, and postoperative outcomes. VSP facilitates immediate dental implantation in selected patients, which can improve the likelihood of achieving dental restoration. This article outlines strategies for technique optimization as well as the applications, advantages and disadvantages of VSP in complex oncologic head and neck reconstruction.
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19
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Precision of Low-Cost Augmented Reality in Prefabricated Cutting Guide for Fibular Free Flap Surgery. J Craniofac Surg 2021; 33:916-919. [PMID: 34369465 DOI: 10.1097/scs.0000000000008074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Augmented reality (AR) is an imaging technology encompassing an interactive experience of a real-world environment enhanced by computer-generated perceptual information. It has been introduced to current medical practice to help the preoperative planning in many surgical fields. METHODS The authors applied AR to the computed tomography angiography of 8 patient's legs. Computed tomography angiography images were processed into Digital Imaging and Communications in Medicine files to make a prefabricated cutting guide and customized titanium plate. Also, three-dimensional reconstruction of the arterial supply of the leg was performed to identify the perforators. RESULTS Followed by preoperative marking of operative details on patient's skins in antero-posterior view, lateral view, and combination of both views. Inaccuracy of measurement was confirmed by duplex ultrasound which average error of the combination of antero-posterior and lateral viewed of both legs was lowest (0.7 ± 0.2 cm). Followed by lateral view (1.0 ± 0.3 cm) and antero-posterior view (1.2 ± 0.4 cm), respectively. CONCLUSIONS Augmented reality can improve patient's safety by directly locate the perforator and easily to design the skin paddle. Followed by satisfaction and confidence in patients and their relatives. Augmented reality also promoted understanding of operative steps for related assistants, residents, or fellows. Augmented reality can perform with existing equipment, mobile phone application, and can save the cost for preoperative planning. Distortion in the depth view can be more accurate by combining of AR in antero-posterior and lateral view.
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20
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Ma H, Shujaat S, Van Dessel J, Sun Y, Bila M, Vranckx J, Politis C, Jacobs R. Adherence to Computer-Assisted Surgical Planning in 136 Maxillofacial Reconstructions. Front Oncol 2021; 11:713606. [PMID: 34336702 PMCID: PMC8322949 DOI: 10.3389/fonc.2021.713606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To investigate the adherence to initially planned maxillofacial reconstructions using computer-assisted surgery (CAS) and to identify the influential factors affecting its compliance for maxillofacial reconstruction. Patients and Methods A retrospective analysis of 136 computer-assisted maxillofacial reconstructive surgeries was conducted from January 2014 to June 2020. The categorical parameters involved age, gender, disease etiology, disease site, defect size, bone flap segments, and flap type. Apart from descriptive data reporting, categorical data were related by applying the Fisher-exact test, and a p-value below 5% was considered statistically significant (P < 0.05). Results The main reasons for partial or non-adherence included unfitness, patient health condition, and other subjective reasons. Out of the total patient population, 118 patients who underwent mandibular reconstruction showed higher CAS compliance (83.9%) compared to the 18 midface reconstruction (72.2%) without any statistically significant difference (p = 0.361). Based on the size of the defect, a significantly higher CAS compliance (p = 0.031) was observed with a minor defect (80.6%) compared to the large-sized ones (74.1%). The bone flaps with two or more segments were significantly (p = 0.003) prone to observe a partial (15.4%) or complete (12.8%) discard of the planned CAS compared to the bone flaps with less than two segments. The malignant tumors showed the lowest CAS compliance when compared to other disorders without any significant difference (p = 0.1). Conclusion The maxillofacial reconstructive surgical procedures offered optimal compliance to the initially planned CAS. However, large-sized defects and multiple bone flap segments demonstrated a higher risk of partial or complete abandonment of the CAS.
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Affiliation(s)
- Hongyang Ma
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sohaib Shujaat
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Van Dessel
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Yi Sun
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Michel Bila
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jan Vranckx
- Department of Plastic, Reconstructive, and Aesthetic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- OMFS IMPATH Research Group, Department of Imaging & Pathology, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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21
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Computer-Aided Design and Manufacturing versus Conventional Surgical Planning for Head and Neck Reconstruction: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2021; 148:183-192. [PMID: 34076623 DOI: 10.1097/prs.0000000000008085] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Virtual surgical planning and computer-aided design/computer-aided manufacturing (CAD/CAM) for complex head and neck reconstruction has a number of cited advantages over conventional surgical planning, such as increased operative efficiency, fewer complications, improved osseous flap union, immediate osseointegrated dental implant placement, and superior functional and aesthetic outcomes. The authors performed a systematic review and meta-analysis of the available evidence on CAD/CAM maxillofacial reconstruction with the primary purpose of determining which approach is more efficacious. METHODS In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed and Embase database search was performed to identify English-language, human-subject studies of CAD/CAM-assisted head and neck reconstruction. All comparative studies were included in a meta-analysis to identify differences in operative time, ischemia time, surgical-site occurrence, microvascular complication, and partial or total flap loss between the two groups. All included studies (comparative and noncomparative) were used in the systematic review, summarizing the various flap characteristics, technical nuances, and functional and aesthetic outcomes. RESULTS Twelve articles were included in the meta-analysis, representing 277 patients in the CAD/CAM group and 419 patients in the conventional group. CAD/CAM was associated with 65.3 fewer minutes of operating room time (95 percent CI, -72.7 to -57.9 minutes; p < 0.0001) and 34.8 fewer minutes of ischemia time (95 percent CI, -38 to -31.5 minutes; p < 0.0001). There were no significant differences in surgical-site occurrence, nonunion, flap loss, microvascular complications, or hardware-related complications. CONCLUSIONS CAD/CAM is associated with shorter operating room and ischemia times. There are no significant differences in flap or hardware-related complications between CAD/CAM and conventional surgical planning.
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22
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Cost-Effectiveness and Virtual Surgical Planning in Head and Neck Reconstruction: Measuring What Matters Most. Plast Reconstr Surg 2021; 147:1091e-1092e. [PMID: 34019529 DOI: 10.1097/prs.0000000000007963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Bender-Heine A, Petrisor D, Wax MK. Advances in Oromandibular Reconstruction with Three-Dimensional Printing. Facial Plast Surg 2020; 36:703-710. [PMID: 33368125 DOI: 10.1055/s-0040-1721110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The mandibular structures are a complex anatomical structure that is fundamental to many physiological and homeostatic functions. It may be involved in many pathological processes that require partial or complete removal. When this happens, reconstruction is mandatory to improve cosmetic outcome with its effect on social interaction as well as to provide an opportunity for complete dental rehabilitation with restoration of all physiological functions. This article will review the different reconstructive options available for complex defects of the mandibular complex. It will highlight the surgical options available to maximize functional restoration. Finally, it will discuss computer modeling to optimize reconstructive planning.
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Affiliation(s)
- Adam Bender-Heine
- Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon
| | - Daniel Petrisor
- Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon
| | - Mark K Wax
- Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon
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Barry CP, MacDhabheid C, Tobin K, Stassen LF, Lennon P, Toner M, O'Regan E, Clark JR. 'Out of house' virtual surgical planning for mandible reconstruction after cancer resection: is it oncologically safe? Int J Oral Maxillofac Surg 2020; 50:999-1002. [PMID: 33317906 DOI: 10.1016/j.ijom.2020.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/14/2020] [Accepted: 11/06/2020] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to investigate whether the time delay between 'out of house' proprietary virtual surgical planning (OH-VSP) of the mandibular resection for oral cancer and the actual surgery results in compromised margins and oncological disadvantage for the patient. Outcomes of patients who had OH-VSP of their mandibular resection and reconstruction were compared with those of patients who had the same surgery using a conventional non-VSP approach. The groups were similar in patient demographics, tumour stage and size, nodal status, and reconstruction complexity. VSP resulted in a significant reduction in operating time (P<0.01). VSP did not affect bony (P=0.49) or soft tissue (P=0.22) margin status. In summary, VSP reduced the operating theatre time, and despite the time interval between bony resection planning and surgery, there was no compromise to the oncological safety of the operation.
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Affiliation(s)
- C P Barry
- Head and Neck Surgery Unit, St James's Hospital, Dublin, Ireland; School of Medicine, Trinity College, Dublin, Ireland; School of Dental Science, Trinity College, Dublin, Ireland.
| | - C MacDhabheid
- Head and Neck Surgery Unit, St James's Hospital, Dublin, Ireland
| | - K Tobin
- School of Medicine, Trinity College, Dublin, Ireland; Global Brain Health Institute, Trinity College Dublin, Ireland
| | - L F Stassen
- Head and Neck Surgery Unit, St James's Hospital, Dublin, Ireland; School of Medicine, Trinity College, Dublin, Ireland
| | - P Lennon
- Head and Neck Surgery Unit, St James's Hospital, Dublin, Ireland; School of Medicine, Trinity College, Dublin, Ireland
| | - M Toner
- School of Dental Science, Trinity College, Dublin, Ireland; Department of Histopathology, St James's Hospital, Dublin, Ireland
| | - E O'Regan
- School of Medicine, Trinity College, Dublin, Ireland; Department of Histopathology, St James's Hospital, Dublin, Ireland
| | - J R Clark
- Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, Australia; Central Clinical School, University of Sydney, Sydney, Australia; Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, Australia
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25
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The use of medical modeling in microvascular free tissue transfer reconstruction with osseointegrated implantation in complex midface defects. Oral Oncol 2020; 110:104982. [DOI: 10.1016/j.oraloncology.2020.104982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 08/16/2020] [Accepted: 08/23/2020] [Indexed: 11/17/2022]
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26
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Wang E, Durham JS, Anderson DW, Prisman E. Clinical evaluation of an automated virtual surgical planning platform for mandibular reconstruction. Head Neck 2020; 42:3506-3514. [DOI: 10.1002/hed.26404] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/12/2020] [Accepted: 07/14/2020] [Indexed: 01/14/2023] Open
Affiliation(s)
- Edward Wang
- Division of Otolaryngology, Department of Surgery University of British Columbia, Gordon and Leslie Diamond Health Care Centre Vancouver British Columbia Canada
| | - J. Scott Durham
- Division of Otolaryngology, Department of Surgery University of British Columbia, Gordon and Leslie Diamond Health Care Centre Vancouver British Columbia Canada
| | - Donald W. Anderson
- Division of Otolaryngology, Department of Surgery University of British Columbia, Gordon and Leslie Diamond Health Care Centre Vancouver British Columbia Canada
| | - Eitan Prisman
- Division of Otolaryngology, Department of Surgery University of British Columbia, Gordon and Leslie Diamond Health Care Centre Vancouver British Columbia Canada
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Zeiderman MR, Pu LLQ. Contemporary reconstruction after complex facial trauma. BURNS & TRAUMA 2020; 8:tkaa003. [PMID: 32341916 PMCID: PMC7175762 DOI: 10.1093/burnst/tkaa003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/07/2020] [Indexed: 11/12/2022]
Abstract
Complex facial trauma requires complex repair and solutions. This process is challenging for the surgeon who seeks to manage the expectations of the patient and family while achieving the best possible result. Historically, the use of pedicled flaps, and then free tissue transfer, were the primary techniques utilized. Advancements in soft-tissue reconstruction, such as perforator flaps and pre-expanded and prefabricated flaps, allow refinement of the soft-tissue reconstruction process to create the best initial soft-tissue coverage. The advent of contemporary technologies, such as virtual surgical planning, stereolithography and customized implants and plates, facilitates a tailored approach to the patient’s reconstructive needs for precise bony reconstruction. When surgical and technological techniques are combined in complementary multistage reconstructions, better reconstructive and aesthetic outcomes are achievable than ever before. In this review, the authors present a summary of the management of complex facial trauma based on the senior author’s broad experience. Initial management and contemporary reconstructive techniques and technology to provide optimal outcomes are reviewed. A case series of complex facial traumas and their reconstructive process is also presented to demonstrate how complementary staged procedures can yield an optimal result. We believe the reconstructive surgeon managing complex facial trauma should strive to incorporate contemporary technologies and techniques into their armamentarium to provide the best patient care.
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Affiliation(s)
- Matthew R Zeiderman
- Division of Plastic Surgery, Department of Surgery, University of California, Davis, 2335 Stockton Boulevard, Room 6008 Sacramento, CA 95817, USA
| | - Lee L Q Pu
- Division of Plastic Surgery, Department of Surgery, University of California, Davis, 2335 Stockton Boulevard, Room 6008 Sacramento, CA 95817, USA
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28
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Mazzola F, Smithers F, Cheng K, Mukherjee P, (Hubert) Low TH, Ch'ng S, Palme CE, Clark JR. Time and cost-analysis of virtual surgical planning for head and neck reconstruction: A matched pair analysis. Oral Oncol 2020; 100:104491. [DOI: 10.1016/j.oraloncology.2019.104491] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/21/2019] [Accepted: 11/23/2019] [Indexed: 11/28/2022]
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