Deviation From Virtual Surgical Plan in Free Fibula Flap Reconstruction for Oral Squamous Cell Carcinoma
Dorothy W. Bird, MD, Nayel Khan, MD, Irene Ma, MD, Erin Anstadt, Simion I. Chiosea, MD, Seungwon W. Kim, MD, Mario G. Solari, MD.
University of Pittsburgh, Pittsburgh, PA, USA.
BACKGROUND: The osteocutaneous fibular free flap (OCFFF) is currently considered to be the gold standard for mandibular reconstruction in cases of head and neck cancer resection. With the advent of computer-aided design and three-dimensional printing virtual surgical planning (VSP) has been proven to have many advantages over traditional intraoperative template creation. To use VSP the resecting surgeon must predict mandibular osteotomies that will result in cancer-free margins based on preoperative CT scans. On occasion the planned osteotomies must be revised at the time of surgery due to unexpected divergence between radiographic and clinical disease. With the temporal and economic investment in VSP the incidence of deviation is critical in assessing its value and oncologic safety.
METHODS: A retrospective review of prospectively-collected data was performed from our free flap database of consecutive patients who underwent mandibular reconstruction with OCFFF for oral squamous cell carcinoma (SCC) by a single plastic surgeon. The incidence of positive bony margins and alterations in final osteotomies due to intraoperative assessment was determined for the cohort. Time from planning CT to surgery was also assessed.
RESULTS: 70 consecutive patients underwent mandibular reconstruction after composite resection for SCC with OCFFF. VSP was used by the surgeon in 43 patients and not used in 27 patients based on availability and feasibility of the technology. 7% (n=3) of those who had VSP mandated a change in osteotomy plan and deviation of the VSP intraoperatively. Osseous margins were positive for cancer in 4% (n=3) of the entire group; one in the VSP group and two in the non-VSP group. The average number of days between planning CT scan to surgery was 21 days in the entire group, 33 days in the group with positive bone margins and 18 days when the VSP plan was adjusted.
CONCLUSIONS: We have shown that changes in mandibular osteotomies at the time of ablative surgery remain rare in the era of VSP and that VSP is oncologically safe in this context. The reconstructive surgeon must anticipate occasional deviation from the VSP and remain prepared for impromptu template design.
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