Keywords
Surgery, plastic - Head and neck neoplasms - Mandibular reconstruction - Free tissue
flaps - Computer simulation
INTRODUCTION
The advent of new technologies has led to the replacement of many traditional treatments
across different areas of clinical practice. Among these technologies, computer simulation
has allowed clinicians to develop a preoperative plan for craniofacial operations
and perform simulation surgeries in a virtual space that can produce a more accurate
execution of the real procedure [1]
[2]
[3]
[4]. Traditionally, mandibular segmental defects following oncological resection have
been reconstructed using fibular free flaps. For the perfect reconstruction of the
mandible, an ideal mandibular contour should be designed such that the fibular bone
has the contoured shape of the original mandible as well as the correct mandibular
positioning for the restoration of the occlusion. For these purposes, multiple osteotomies
are inevitable by using conventional procedures. However, although conventional shaping
of the osteotomies is possible, a more convenient and accurate design is feasible
with the use of computer simulations [5]
[6]
[7]. Hence, in this report, we describe the surgical treatment of a patient with a fibular
osteotomy guide that was based on virtual computer simulation surgery for mandibular
segmental reconstruction.
DISCUSSION
Since its introduction by Hidalgo [8] in 1989, contouring of a free fibular flap has been classically performed with a
freehand approach. Although acceptable results can be obtained using this method,
a learning curve on the part of the surgeon is needed for the ideal contouring of
the mandible. Computer simulation surgery was introduced in the early 1990s [9]. However, despite the remarkable advancements in this technology since then, the
actual application of virtual surgery has been quite limited in clinical practice.
This is due to several factors that include the complexity involved in manipulating
the computer software, the time-consuming nature of the simulation processes, high
costs, and the difficulty of applying the results of the simulation surgery to real
surgery. However, recent advancements in simulation technology are beginning to overcome
these obstacles.
With respect to the complexity of the computer software, the manipulation process
has been considerably simplified in recent years. Although some difficulties remain
in this regard from a technical perspective, many of these can be overcome with the
assistance of simulation experts. The problem related to the time required to conduct
simulations can now be addressed with the expert assistance of computer simulation
companies. These businesses are currently providing services that will greatly reduce
the time that clinicians will need to spend when conducting virtual procedures. The
cost of performing simulations remains an issue and can range from 1,000 to 10,000
US dollars. We have been able to reduce these costs by using a custom-made guide.
Finally, the ability to move from a simulation to an actual surgery can be addressed
in two ways. One solution is to use navigational surgery that can mimic the simulation
results in real surgical fields by using 3D positioning rods that are fixed on the
skull, face, or denture. However, the cost of the navigation approach is still quite
high, and precise positioning is often difficult without frequent default manipulations.
The second option is the use of a surgical guide. A fibular osteotomy guide is a good
example of this and can effectively serve to connect the parameters and results of
simulation surgery with those of a real surgical procedure. Traditionally, this kind
of surgical guide has been used in orthognathic operations as a form of surgical splint
for occlusion. A surgical wafer is a tool used to connect mock surgery with an actual
orthognathic procedure. Likewise, a fibular osteotomy guide has utility for this purpose.
On the basis of our experiences in this current case report, we have concluded that
a fibular osteotomy guide is a very useful and effective tool for performing a mandibular
reconstruction with the fibular free flap. As the computer simulation technologies
continue to progress rapidly, computer simulations are likely to become principal
clinical and surgical tools in the near future.
This article describes our experience in surgically treating a mandibular segmental
defect by using a unique computer simulation method developed in our clinic. The findings
presented in this report indicate that the application of a fibular osteotomy guide
based on simulation surgery is a feasible approach to achieving more effective, accurate,
and simplified mandibular reconstructions. This is an important advance as there has
been no previous report that has described the application of an osteotomy guide based
on computer-simulated virtual surgery.
