DISCUSSION Discussion: Computer-Assisted versus Conventional Free Fibula Flap Technique for Craniofacial Reconstruction: An Outcomes Comparison Evan Matros, M.D. Joseph J. Disa, M.D. New York, N.Y.
T
he current study is a retrospective review of a single surgeon’s experience in craniofacial reconstruction using conventional fibula flap shaping techniques from 2003 to 2009 (n = 58) versus computer-aided design/computer-aided manufacturing from 2010 to 2012 (n = 10).1 Since the two techniques were used consecutively, not concurrently, a temporal bias is present; however, the statistical analysis highlights some worthwhile differences. The first advantage demonstrated with computer-aided design and manufacturing over conventional methods was decreased flap ischemia time, which was reduced by approximately 50 minutes. The authors cite time savings in the following areas: (1) preplanning of osteotomies aided by the use of intraoperative cutting jigs, (2) creation of a prebent reconstruction plate, (3) confirmation of flap shape to a stereolithographic model prior to pedicle division, and (4) osteotomy creation with the pedicle intact rather than free-handing on the back table. We agree that the first three areas are benefits of computer-aided design and manufacturing that can reduce ischemic time, but we disagree that flap shaping with traditional methods needs to be performed after pedicle division, since this is routine in many centers. While potential time savings would be a means of recouping the added cost of computer-aided design and manufacturing, overall operative time was no different for the two techniques. Time savings with computer-aided design and manufacturing also need to be considered in light of the additional time it takes to complete the preoperative virtual modeling session, which can take up to an hour.
From the Memorial Sloan-Kettering Cancer Center. Received for publication June 14, 2013; accepted June 24, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000436749.19277.12
The most interesting and illuminating finding of the study is the increased number of flap bone segments used for similar size defects when reconstructed with computer-aided versus conventional techniques. For comparable periorbital and infrastructure maxillectomy defects, the use of additional bone segments was associated with a more refined subjective reconstructive result (see authors’ Figures 4 through 7). Because the native craniofacial contour changes significantly through small distances, improved results can be achieved with multiple smaller fragments. This benefit must be weighed against the risk of ischemia when bone segments are smaller than 2 cm. Although not specifically stated, but illustrated in the authors’ cases chosen for discussion, one of the greatest advantages of computer-aided design and manufacturing over traditional methods is for maxillary defects. The complex three-dimensional spatial relationships in this anatomic area combined with limited operative exposure can preclude adequate visualization and accurate flap insetting. While others have recommended intraoperative navigation to assist flap placement for this reason, stereolithograph-derived computer-aided design and manufacturing models provide similar assistance.2 Since Hidalgo performed the first fibula flap for mandible reconstruction over 20 years ago, innumerable osseous reconstructions have been performed successfully. While reconstructive accuracy with computer-aided design and manufacturing has been demonstrated in the current and other studies, the real challenge is to demonstrate superiority over traditional shaping methods to justify the added cost.3 Perhaps the goal of future investigations should be to identify the subset of cases most likely to benefit from this Disclosure: The authors have no financial interest to declare in relation to this Discussion or the associated article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • November 2013 technology, such as maxillary or delayed cases, as computer-aided reconstruction is unlikely to provide a meaningful clinical difference over traditional shaping methods for most straightforward osseous defects. Joseph J. Disa, M.D. Division of Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center 1275 York Avenue New York, N.Y. 10065 [email protected]
FILLER-059
REFERENCES
1. Seruya M, Fisher M, Rodriguez ED. Computer-assisted versus conventional free fibula flap technique for craniofacial reconstruction: An outcomes comparison. Plast Reconstr Surg. 2013;132:1219–1228. 2. Hanasono MM, Jacob RF, Bidaut L, et al. Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation. Plast Reconstr Surg. 2010;126:2002–2006. 3. Roser SM, Ramachandra S, Blair H, et al. The accuracy of virtual surgical planning in free fibula mandibular reconstruction: Comparison of planned and final results. J Oral Maxillofac Surg. 2010;68:2824–2832.
Plastic Surgery Level of Evidence Rating Scale—Diagnostic Studies
Level of Evidence I II III IV V
Qualifying Studies Highest-quality, multicentered or single-centered, cohort study validating a diagnostic test (with “gold” standard as reference) in a series of consecutive patients; or a systematic review of these studies Exploratory cohort study developing diagnostic criteria (with “gold” standard as reference) in a series of consecutive patient; or a systematic review of these studies Diagnostic study in nonconsecutive patients (without consistently applied “gold” standard as reference); or a systematic review of these studies Case-control study; or any of the above diagnostic studies in the absence of a universally accepted “gold” standard Expert opinion developed via consensus process; case report or clinical example; or evidence based on physiology, bench research, or “first principles”
Find out more from the “Evidence-Based Medicine: How-to Articles” Collection at www.PRSJournal.com
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T
he current study is a retrospective review of a single surgeon’s experience in craniofacial reconstruction using conventional fibula flap shaping techniques from 2003 to 2009 (n = 58) versus computer-aided design/computer-aided manufacturing from 2010 to 2012 (n = 10).1 Since the two techniques were used consecutively, not concurrently, a temporal bias is present; however, the statistical analysis highlights some worthwhile differences. The first advantage demonstrated with computer-aided design and manufacturing over conventional methods was decreased flap ischemia time, which was reduced by approximately 50 minutes. The authors cite time savings in the following areas: (1) preplanning of osteotomies aided by the use of intraoperative cutting jigs, (2) creation of a prebent reconstruction plate, (3) confirmation of flap shape to a stereolithographic model prior to pedicle division, and (4) osteotomy creation with the pedicle intact rather than free-handing on the back table. We agree that the first three areas are benefits of computer-aided design and manufacturing that can reduce ischemic time, but we disagree that flap shaping with traditional methods needs to be performed after pedicle division, since this is routine in many centers. While potential time savings would be a means of recouping the added cost of computer-aided design and manufacturing, overall operative time was no different for the two techniques. Time savings with computer-aided design and manufacturing also need to be considered in light of the additional time it takes to complete the preoperative virtual modeling session, which can take up to an hour.
From the Memorial Sloan-Kettering Cancer Center. Received for publication June 14, 2013; accepted June 24, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000436749.19277.12
The most interesting and illuminating finding of the study is the increased number of flap bone segments used for similar size defects when reconstructed with computer-aided versus conventional techniques. For comparable periorbital and infrastructure maxillectomy defects, the use of additional bone segments was associated with a more refined subjective reconstructive result (see authors’ Figures 4 through 7). Because the native craniofacial contour changes significantly through small distances, improved results can be achieved with multiple smaller fragments. This benefit must be weighed against the risk of ischemia when bone segments are smaller than 2 cm. Although not specifically stated, but illustrated in the authors’ cases chosen for discussion, one of the greatest advantages of computer-aided design and manufacturing over traditional methods is for maxillary defects. The complex three-dimensional spatial relationships in this anatomic area combined with limited operative exposure can preclude adequate visualization and accurate flap insetting. While others have recommended intraoperative navigation to assist flap placement for this reason, stereolithograph-derived computer-aided design and manufacturing models provide similar assistance.2 Since Hidalgo performed the first fibula flap for mandible reconstruction over 20 years ago, innumerable osseous reconstructions have been performed successfully. While reconstructive accuracy with computer-aided design and manufacturing has been demonstrated in the current and other studies, the real challenge is to demonstrate superiority over traditional shaping methods to justify the added cost.3 Perhaps the goal of future investigations should be to identify the subset of cases most likely to benefit from this Disclosure: The authors have no financial interest to declare in relation to this Discussion or the associated article.
www.PRSJournal.com
1229
Plastic and Reconstructive Surgery • November 2013 technology, such as maxillary or delayed cases, as computer-aided reconstruction is unlikely to provide a meaningful clinical difference over traditional shaping methods for most straightforward osseous defects. Joseph J. Disa, M.D. Division of Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center 1275 York Avenue New York, N.Y. 10065 [email protected]
FILLER-059
REFERENCES
1. Seruya M, Fisher M, Rodriguez ED. Computer-assisted versus conventional free fibula flap technique for craniofacial reconstruction: An outcomes comparison. Plast Reconstr Surg. 2013;132:1219–1228. 2. Hanasono MM, Jacob RF, Bidaut L, et al. Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation. Plast Reconstr Surg. 2010;126:2002–2006. 3. Roser SM, Ramachandra S, Blair H, et al. The accuracy of virtual surgical planning in free fibula mandibular reconstruction: Comparison of planned and final results. J Oral Maxillofac Surg. 2010;68:2824–2832.
Plastic Surgery Level of Evidence Rating Scale—Diagnostic Studies
Level of Evidence I II III IV V
Qualifying Studies Highest-quality, multicentered or single-centered, cohort study validating a diagnostic test (with “gold” standard as reference) in a series of consecutive patients; or a systematic review of these studies Exploratory cohort study developing diagnostic criteria (with “gold” standard as reference) in a series of consecutive patient; or a systematic review of these studies Diagnostic study in nonconsecutive patients (without consistently applied “gold” standard as reference); or a systematic review of these studies Case-control study; or any of the above diagnostic studies in the absence of a universally accepted “gold” standard Expert opinion developed via consensus process; case report or clinical example; or evidence based on physiology, bench research, or “first principles”
Find out more from the “Evidence-Based Medicine: How-to Articles” Collection at www.PRSJournal.com
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![[Condylar remodelling after temporomandibular joint reconstruction with fibula free flap].](/assets/img/hold.png)
