The New Age of Three-Dimensional Virtual Surgical Planning in Reconstructive Plastic Surgery (2012)

Sir:FigureIt was with great pleasure that we read your recent article entitled "Use of Virtual Surgery and Stereolithography-Guided Osteotomy for Mandibular Reconstruction with the Free Fibula."1 We commend the authors, Antony et al., for their exciting work using three-dimensional imaging technology to further enhance free fibula reconstruction of the mandible. In their study, they report their experience with five patients who underwent composite mandibular resection with the aid of virtual planned reconstruction. They report 100 percent success with the use of cutting guides to direct oncologic resection and fibula reconstruction of the mandible. We congratulate this group for their ongoing work in bringing to light an exciting area of plastic and reconstructive surgery. Our group first described the use of virtual planning for fibular reconstruction of the mandible in 2009,2 and virtual three-dimensional planning continues to rapidly be adopted as a novel technique for reconstructive plastic surgery. Since this report, the authors along with a number of other surgeons worldwide have continued to explore the potential of virtual planning to other areas of reconstructive surgery, including craniofacial surgery and posttraumatic deformities.3 To date, we have gained over 3 years of experience with virtual planning in free-fibula mandible reconstruction with a total of 75 patients at our two institutions. Although our first generation of virtual planning in the fibular reconstruction of the mandible represented a similar approach as described by Antony et al., we feel that it is important to point out for the readers of Plastic and Reconstructive Surgery the critical advancements that have been made. Both Antony et al. and our group initially report the use of cutting and positioning guides to aid in both resection and reconstruction. One important feature that currently exists and that has yet to be reported in the literature is the placement of dental implants at the time of initial surgery. We have found that through virtual planning the surgeon has the capability to plan and in turn directly place implants onto the fibular segment while attached to the pedicle before final division. With virtual planning, one has the capability to determine the true dimensions of the patient's fibula and the ability to successfully place implants. If concerns for bone stock do arise, one can then plan for a double-barreled free flap to be used. We have found virtual planning to be particularly helpful in such cases where double-barreling is required and that otherwise may be difficult to "free hand" from a three-dimensional perspective. Perhaps the most significant advance that we have now made with this technology is planning of not only the initial implant but also the prosthesis. With careful preoperative virtual planning among the prosthodontist and the oncologic, plastic, and oral and maxillofacial surgeons, three-dimensional virtual technology now affords the ability to plan and construct a fibula with implants and a dental prosthetic as a single-stage procedure. In this regard, a patient undergoing composite mandible reconstruction leaves the operating room with a full complement of teeth. An example of this type of reconstruction is shown in Figure 1.Fig. 1: Reconstruction using three-dimensional virtual technology.An important criticism of the work by Antony et al. is the lack of any objective data comparing "virtual" plan to surgical outcomes. Roser et al. recently published their review of 11 patients who underwent virtual planning for free-fibula reconstruction of the mandible.4 Three-dimensional comparisons demonstrated a mean overlap of 59 percent, with minimal deviation from the planned reconstruction. This type of analysis is essential as this technology evolves, as is the study of other important parameters such as operative time and total cost. We hope this discussion adds to the ongoing work by various physicians worldwide using virtual planning in reconstruction of the jaw. We look forward to other exciting reports from such groups and await critical review of this technology in years to come. Oren Tepper, M.D. David Hirsch, M.D., D.D.S. Jamie Levine, M.D. Evan Garfein, M.D. Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication.