Journal of Plastic, Reconstructive & Aesthetic Surgery
ReviewAdvances in oncologic head and neck reconstruction: Systematic review and future considerations of virtual surgical planning and computer aided design/computer aided modeling
Introduction
Virtual surgical planning (VSP) in the area of reconstructive surgery is a new technology that is gaining acceptance due to its many perceived benefits including increased accuracy, improved operative efficiency and enhanced outcomes.1, 2 A number of authors have described using VSP in craniofacial reconstruction, with indications ranging from trauma to oncologic reconstruction.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 Refinements in the use of computer aided design (CAD) and computer aided modeling (CAM) for preoperative planning now offers a more facile user interface lending itself to greater draw and adoption in reconstructive applications requiring precise planning and execution.1, 6, 24, 26 In particular, VSP has gained traction for use in reconstruction of the mandible and maxilla, as surgical accuracy is required to restore facial symmetry, appearance, and function; a task complicated by the irregular, unique shapes of the maxillo-mandibular construct and the relative lack of similarly-shaped graft donor sites.11 VSP is an exciting new technology that warrants consideration for use in complex oncologic osseous head and neck reconstruction.
Multi-stage implementation of virtual surgical planning with use of cutting guides, stereolithographic models and pre-fabricated plates offers reconstructive accuracy previously reliant on surgeon experience and intraoperative trial-and-error using 2D imaging modalities. Cited reconstructive benefits of CAD/CAM implementation include increased bone-to-bone contact, better dental alignment, improved esthetic contour, and reduced complication rates.11, 37 As an increasing number of authors are reporting on VSP in oncologic craniomaxillofacial surgery, we sought to investigate the benefits of the technology by performing a systematic review of the literature to identify usage and assess advantages for an oncologic indication. Additionally, to determine the utility of VSP in reconstruction of the head and neck, a comparison of surgical outcomes against those of conventional craniomaxillofacial surgery will be included. This is the first and only systematic review-to-date regarding the utility of virtual surgical planning in oncologic head and neck reconstruction, with a focus on reconstruction of the maxilla and mandible. We will also present sample cases highlighting our experience with VSP in head and neck reconstruction.
Section snippets
Surgical technique
Computer assisted craniomaxillofacial surgery is based on four specific, well-described phases, which are all necessary in order to achieve predictable outcomes: planning, modeling, surgery, and evaluation.3, 17 These steps are detailed as follows:
The first phase, planning, beings with a high-resolution computed tomographic (CT) scan with thin cuts of the craniofacial skeleton and the possible donor sites, (e.g. lower extremities) if considered necessary. A 3D reconstruction of the CT images is
Case 1
A 23 year-old man presented with left lower jaw swelling and after subsequent workup was found to have an ameloblastoma of the left mandible. VSP aided in reconstructive planning given challenges arising from the significant extent of the lesion beyond the normal borders of the mandible, distorting facial contour and symmetry and impairing the ability to bend a reconstructive plate in-situ onto the native mandible. CAM facilitated creation of a stereolithographic model of the reconstruction,
Methods
A systematic review of the current literature was conducted using PubMed and Cochrane Reviews by three independent reviewers. The search terms used were: “computer assisted design”, “reconstruction”, “flap”, “craniomaxillofacial surgery”, “virtual design”, “reconstructive surgery”, and “oncologic”. Three separate search schemes were utilized, providing a total of 82 articles. (Figure 7) Inclusion and exclusion criteria were then applied to the search results as outlined. Additional articles
Results
The systematic literature review yielded 82 articles, and of these, 33 met inclusion criteria. These articles described a total of 220 cases of oncologic head and neck reconstruction incorporating virtual planning technology, of which the majority were for mandibular reconstructions (193 cases, 88%) and the remaining were for maxillary reconstructions (22 cases, 10%). The patients in the series ranged from 13 to 84 years old (average 48 years old) and follow up ranged from 3 weeks to 7 years
Discussion
Virtual surgical planning is an exciting new technology that warrants consideration for complex craniofacial reconstruction, with potential to transform the approach and execution of challenging oncologic head and neck reconstructions.26 Traditional methods of reconstruction typically rely on intraoperative trial-and-error and accumulated surgeon experience, and may engender constraints in achieving consistent, predictable orthognathic and esthetic outcomes.2 Among the reported benefits of
Conclusion
VSP represents an evolving technology that ushers oncological craniofacial reconstruction into a modern era, holding the potential to consistently and predictably advance reconstructive outcomes, both aesthetically and functionally. Implementation of VSP-CAD/CAM into each stage of the reconstruction affords the opportunity to reduce human translational error and facilitates intraoperative decision-making with expedition of the surgical phase. While there are emerging qualitative improvements
Ethical approval
Approval was granted by the University of Illinois Institutional Reveiw Board for the case reports.
Funding
None.
Conflicts/disclosures
The authors have no relevant financial disclosures.
Conflict of interest
None.
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