Subjective Assessment of Head and Facial Appearance in Children with Craniosynostoses after Surgical Treatment

From Augmented to Virtual Reality in Plastic Surgery: Blazing the Trail to a New Frontier

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.

The Esthetic Perception of Morphological Severity in Scaphocephalic Patients is Correlated With Specific Head Geometrical Features

OBJECTIVE

To investigate the relationship between perception of craniofacial deformity, geometric head features, and 3D head shape analyzed by statistical shape modeling (SSM).

PATIENTS

A total of 18 unoperated patients with scaphocephaly (age  =  5.2  ±  1.1m)-6 were followed-up after spring-assisted cranioplasty (SAC) (age  =  9.6  ±  1.5m)-and 6 controls (age  =  6.7  ±  2.5m).

MAIN OUTCOME MEASURES

3D head shapes were retrieved from 3D scans or computed tomography (CTs). Various geometrical features were measured: anterior and posterior prominence, take-off angle, average anterior and posterior lateral and horizontal curvatures, cranial index (CI) (cranial width over length), and turricephaly index (TI) (cranial height over length). SSM and principal component analysis (PCA) described shape variability. All models were 3D printed; the perception of deformity was blindly scored by 9 surgeons and 1 radiologist in terms of frontal bossing (FB), occipital bulleting (OB), biparietal narrowing (BN), low posterior vertex (LPV), and overall head shape (OHS).

RESULTS

A moderate correlation was found between FB and anterior prominence (r  =  0.56, P < .01) and take-off angle (r  =  - 0.57, P < .01). OB correlated with average posterior lateral curvature (r  =  0.43, P < 0.01) similarly to BPN (r  =  0.55, P < .01) and LPV (r  =  0.43, P < .01). OHS showed strong correlation with CI (r  =   - 0.68, P < .01) and TI (r  =  0.63, P< .01). SSM Mode 1 correlated with OHS (r  =  0.66, p < .01) while Mode 3 correlated with FB (r  =   - 0.58, P < .01).

CONCLUSIONS

Esthetic cranial appearance in craniofacial patients is correlated to specific geometric parameters and could be estimated using automated methods such as SSM.

Do standard surgical techniques lead to satisfying aesthetic results in nonsyndromic sagittal suture synostosis?

OBJECTIVE

Surgical correction of synostotic cranial sutures is typically performed early in an affected child's life. Depending on the severity of the cranial synostoses, different aspects of the surgical treatment may have varying degrees of importance. In this sense, the aesthetic appearance in children with normal neurological development in single-suture synostosis plays an important role in self-perception and social acceptance for both the patients themselves and their caregivers. Therefore, in this study, the authors aimed to evaluate the aesthetic outcome after surgical correction in a cohort of patients with nonsyndromic sagittal suture synostosis.

METHODS

Between December 2002 and December 2019, a total of 99 patients underwent surgical correction of a synostotic sagittal suture at the Medical University of Vienna. Depending on their age, patients underwent either an extended midline strip craniectomy (EMSC) (< 4 months) or a modified pi procedure (MPP) (≥ 4 months). After the surgical procedure, the outcome was evaluated by the treating neurosurgeon at 1- and 12-month follow-up visits, and after approximately 5 years, before the patient entered elementary school. In addition to that, the patients' caregivers were asked to evaluate the aesthetic outcome of the surgical procedure after 12 months. These results were then compared to evaluate potential differences in the perception of the surgical outcome.

RESULTS

After 12 months, the majority of the included patients were evaluated as having a good aesthetic outcome by the treating neurosurgeon (97%) and by their caregivers (89%). These differences did not show statistical significance (p = 0.11). Similarly, no differences in the aesthetic outcome depending on the surgical procedure performed could be found (p = 0.55). At the last follow-up visit, before entering elementary school, all available patients had an excellent or good surgical outcome. Moreover, the majority of caregivers (73%) reported that their child had a normal head shape appearance after surgical correction.

CONCLUSIONS

The results of this study have suggested that surgical correction of sagittal suture synostosis by simple operative techniques leads to a good aesthetic outcome and a normal head shape appearance in the majority of patients. An analysis of the evaluation of the surgical outcome by either the treating neurosurgeon or the patient caregivers showed comparable results and, thus, early intervention with simple surgical techniques can be recommended.

Smartphone-assisted Augmented Reality in Craniofacial Surgery

Augmented reality (AR), a blending of both the physical and digital worlds, can be a valid tool for surgeons wishing to plan interventions and attain symmetry. The use of technology has enabled physicians to achieve desirable results. In this article, we describe a method that uses smartphone's simple AR utilities for convenient, cost effective, and time saving perioperative planning.

Methods

Images of preoperative computed tomography, along with 3D reconstructed scans were uploaded to a smartphone and used in an affordable application (Camera Lucida) to superimpose the loaded pictures over the smartphone camera. In one case, a 3D computed tomography scan of the skull was mirrored to help guide fronto-orbital advancement, and in another case the loaded 3D reconstructed computed tomography scan was used to prioritize areas of scalp coverage in a complicated case of craniosynostosis with major scalp wound dehiscence.

Discussion

Adaptation of AR to assist in the field of craniofacial surgery has been introduced before in several studies that reported the use of computer-based guidance for cranial reshaping. The majority of these reports used sophisticated modalities, combining advanced image registration and tracking with specialized equipment. The utility of smartphone AR for cranial vault reconstruction provided good accuracy when visualizing fronto-orbital advancement and remodeling, together with in depth prioritization of areas in need of soft tissue reconstruction.

Conclusion

Smartphone AR adaptation proved to be a very convenient tool assisting in the planning of different craniofacial conditions that are time saving and do not incur any additional fees beyond those of the surgery.