Three-Dimensional Computer-Assisted Surgical Planning, Manufacturing, and Intraoperative Navigation in Oncologic Surgery



Three-Dimensional Computer-Assisted Surgical Planning, Manufacturing, and Intraoperative Navigation in Oncologic Surgery




Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 2020-09-01, Volume 28, Issue 2, Pages 129-144, Copyright © 2020 Elsevier Inc.



Key points

  • Virtual surgical planning can aid both precise resection and accurate reconstruction.

  • Surgical navigation is a technique developed initially for neurosurgery but has been adapted for head and neck resections, particularly involving the midface and base of skull.

  • Surgical navigation in conjunction with virtual surgical planning is useful for reconstructing traumatic defects.


Introduction

Surgery of the head and neck requires the surgeon to meet both functional and esthetic goals when reconstructing traumatic or ablative defects. Reconstruction is complicated by the high esthetic demands of the region; the face plays an important role in a person’s identity and deformity can have a negative psychological effect. To the extent possible, the goal is to achieve symmetry and adequate projection. Functionally, speech, deglutition, and vision should be addressed as well. Rigid internal fixation allows the precise placement of bone and the advent of microvascular reconstructive techniques greatly expands the reconstructive surgeon’s ability to restore defects. Computer-aided surgery (CAS) has become a mainstay of maxillofacial reconstruction as technological advances in imaging, computer-aided design, and manufacturing techniques enable the surgeon to precisely plan and execute the case. Improvements in accuracy and operating time have been demonstrated. , CAS can also be used intraoperatively in conjunction with a navigation system to guide surgical resections, particularly at the skull base, avoid critical structures, assess fracture reduction, and aid with margin identification. , Advances in imaging and computer technology led to the development of frameless navigation systems, which have been incorporated into the current systems used today. , We review the work flow involved in planning and carrying out a case using CAS and navigation.


Steps in computer-aided surgery and navigation


Data acquisition

The first step is data acquisition. This typically requires a fine-cut computed tomography (CT) scan of the face without contrast, with cuts 1 mm or less for adequate resolution. If osseous reconstruction is planned, imaging of the donor site may be indicated, such as a CT angiogram of the lower extremities in the case of a free fibula flap or a CT angiogram of the chest if a scapula flap is to be used. If the maxilla or mandible is involved in the surgical plan, dental records are taken either in the form of stone casts, which are subsequently scanned, or digital impressions, which are combined with the CT face to create a composite 3-dimensional (3D) image with an accurate occlusion. Similarly, soft tissue can be modeled using a 3D camera, merging the soft tissue profile with the underlying skeletal information from the CT. Other modalities, such as MRI, can be merged to create a composite 3D image.


Segmentation

The next step is the process of segmentation, which is the delineation of structures of interest (eg, bone, nerve, vessels). In the past, this was done manually, selecting bone and soft tissue based on Hounsfield units. Today, this step is largely done by the planning software and can be fine-tuned by the engineer assisting in the treatment planning.


Preoperative planning

A meeting is then set up with the commercial vendor and takes place online with an engineer. This portion will of course be tailored to the specific case. If it is pathology, the lesion can be outlined and a margin established. If it is a trauma case, the fracture is identified. Bony cuts can then be simulated on the 3D model; the orientation of the cuts is evaluated in all 3 dimensions to ensure that structures, such as nerves and tooth roots, are avoided. If applicable, the unaffected contralateral side can be mirrored to demonstrate the proper reduction or bony contour. This is helpful in the context of trauma or in a secondary reduction, where the normal anatomy has been lost. Cutting guides are designed and can be tailored to the specific approach used and bone exposure anticipated. They should include a feature to register the guide to the bone. In the dentate portion of the maxilla or mandible, this may be an occlusal guide. Elsewhere, it may be a lip or tab that limits the degrees of freedom of the guide on the bone. Cutting guides can also incorporate predictive holes to predrill the screw holes used in the reconstruction plate. Predictive holes can obviate the need for intermaxillary fixation. If a reconstruction is planned using an osseous free flap, the graft is planned as well to fit the defect. If needed, osteotomies can be planned to contour the graft precisely to the space, which will be incorporated into the cutting guides. Dental rehabilitation can also be planned at this time. Endosseous implants can be incorporated into a fibula, for example, and their placement can be determined at this time. A temporary dental prosthesis can be made off of a stereolithic model. Hardware is then designed and is customized to the patient. In comparison to using stock plates, custom hardware offers great flexibility in terms of shape and screw hole placement. As with the cutting guides, nerves and tooth roots are avoided when designing the plate. The plans are finalized.


Fabrication of models, plates, and guides

Stereolithic models, cutting guides, and custom plates are manufactured. A number of benefits are realized by pre-manufacturing the hardware. For one, operative time can be reduced because the plates do not have be shaped intraoperatively. The hardware enjoys an excellent fit that is hard to replicate with hand bending. Furthermore, the strength of a reconstruction plate is higher than a bent plate because the custom milled plate does not incur the stress of bending. Everything is shipped to the hardware representative and is sterilized before surgery.


Intraoperative registration

If navigation is to be used, registration of the patient is performed before prepping and draping. This process will be unique to each navigation system, but generally involves the accurate orientation of the patient’s skull to the reference imaging in the navigation system using markers called fiducials. A variety of fiducials have been used, from implanted titanium markers, to dental splints, to light-emitting diode (LED)-containing masks. In some systems, a CT is obtained with the fiducial marker in place; for some systems this is not necessary. Intraoperatively, a headset is either anchored to the skull or attached to a mask that is in view of the navigation tower called the locator. An instrument is equipped with either reflectors or LED markers that can be visualized by the locator. The locator is used to identify points on the headset and other fiducials using the handheld instrument. The navigation system uses these points of reference to correlate the patient’s skull with the imaging.


Surgery

Surgery is then performed, using the appropriate approach for the surgical resection or to expose the fracture. If bone is to be resected, the cutting guides are fitted and secured with monocortical screws. Care must be taken to ensure that the cutting guide fits flush with the bone, and is not impeded by soft tissue. Predictive holes are then drilled, which will help maintain the occlusal relationship. The resection is performed. If an osseous flap is being harvested simultaneously, cutting guides are used for the bony flap as well. Implants are placed if applicable. The reconstruction plate can be fitted either to the facial defect, or if applicable, to the osseous free flap before transfer. With the pre-drilled holes, affixing the plate to bone is effortless. For a free flap, the pedicle is then divided and the flap inset.

Intraoperatively, navigation will be used in a manner specific to the surgery. If it is an orbital floor fracture, for example, navigation may be used to confirm the seating of the reconstruction plate on the posterior ledge. For an orbital resection, navigation can be used to navigate the base of skull, or to guide osteotomies. Navigation is often used in conjunction with intraoperative CT or cone-beam CT to confirm an adequate reduction or appropriate reconstruction.


Surgical applications


Orbital reconstruction

Periorbital trauma often results in an enlargement in the orbital volume. This can cause dystopia, enophthalmos, resulting in diplopia. It has historically been difficult to reestablish the pretraumatic orbital volume, complicated as it often is with posttraumatic swelling, limited access, and loss of bony landmarks. CAS provides a predictable approach to reconstructing the orbit. , If the contralateral orbit is unaffected, it can be mirrored and used to simulate the appropriate contours for the reconstructed orbit. A stereolithic model can be created from that simulation and an orbital reconstruction plate adapted to the defect. Custom plates can even be made, largely removing the guesswork of adapting the hardware. Intraoperative navigation can be used to both verify the correct positioning of the plate as well as to avoid critical structures at the orbital apex such as the optic nerve. Alternatively, intraoperative CT is useful to confirm the orbital repair.


Orthognathic surgery

CAS has transformed the work flow for planning orthognathic cases. Traditional model surgery is labor intensive and involves multiple steps; small errors made early on are magnified in the subsequent steps and can cause significant inaccuracy. Furthermore, complex asymmetries are challenging to model using traditional methods. With CAS, a fine-cut CT maxillofacial without contrast is obtained, as are dental models, either digital or digitized from plaster models. These are sent to a third-party vendor and melded together to create an accurate digital representation of the bony skeleton and dentition. Traditional orthognathic measurements and photos are taken as well and used in the analysis. A treatment planning session is arranged and the desired bony cuts are made and the movements simulated. A significant advantage to performing the surgery “virtually” is that bony interferences can be anticipated that can save time in the operating room. Occlusal splints are fabricated and custom cutting guides and plates can even be designed if desired.


Temporomandibular joint surgery

Severe temporomandibular joint disease is often treated with alloplastic reconstruction. Currently, reconstructive options for total joint replacement include stock and patient-specific prostheses. For a custom prosthesis, similar to an orthognathic surgery workup, a fine-cut CT maxillofacial without contrast and digitized dental models are merged. A prosthesis is then fabricated off of a stereolithic model by a third-party vendor. CAS allows complex planning; bilateral joint replacement and simultaneous orthognathic surgery can be reliably executed.


Tumor resection

CAS has applications in the resection of benign and malignant tumors in the head and neck. For odontogenic lesions, or lesions requiring a bony resection, the tumor can be delineated during the process of segmentation, and resection margins are determined during the planning session. Structures such as nerves, vessels, and teeth are identified and avoided if possible or included in the resection.

Navigation also can be useful when resecting head and neck tumors. Some investigators have described the use of navigation to label resection margins. Frozen margins can be identified and marked using navigation. This can orient the pathologist and can aid in identifying areas that need to be re-resected. The labeled imaging also can be useful in communicating margin status with the radiation oncologist.


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Three-Dimensional Computer-Assisted Surgical Planning, Manufacturing, and Intraoperative Navigation in Oncologic Surgery Phillip Harrison DDS, MD , Ashish Patel MD, DDS , Allen Cheng MD, DDS and R. Bryan Bell MD, DDS Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 2020-09-01, Volume 28, Issue 2, Pages 129-144, Copyright © 2020 Elsevier Inc. Key points Virtual surgical planning can aid both precise resection and accurate reconstruction. Surgical navigation is a technique developed initially for neurosurgery but has been adapted for head and neck resections, particularly involving the midface and base of skull. Surgical navigation in conjunction with virtual surgical planning is useful for reconstructing traumatic defects. Introduction Surgery of the head and neck requires the surgeon to meet both functional and esthetic goals when reconstructing traumatic or ablative defects. Reconstruction is complicated by the high esthetic demands of the region; the face plays an important role in a person’s identity and deformity can have a negative psychological effect. To the extent possible, the goal is to achieve symmetry and adequate projection. Functionally, speech, deglutition, and vision should be addressed as well. Rigid internal fixation allows the precise placement of bone and the advent of microvascular reconstructive techniques greatly expands the reconstructive surgeon’s ability to restore defects. Computer-aided surgery (CAS) has become a mainstay of maxillofacial reconstruction as technological advances in imaging, computer-aided design, and manufacturing techniques enable the surgeon to precisely plan and execute the case. Improvements in accuracy and operating time have been demonstrated. , CAS can also be used intraoperatively in conjunction with a navigation system to guide surgical resections, particularly at the skull base, avoid critical structures, assess fracture reduction, and aid with margin identification. , Advances in imaging and computer technology led to the development of frameless navigation systems, which have been incorporated into the current systems used today. , We review the work flow involved in planning and carrying out a case using CAS and navigation. Steps in computer-aided surgery and navigation Data acquisition The first step is data acquisition. This typically requires a fine-cut computed tomography (CT) scan of the face without contrast, with cuts 1 mm or less for adequate resolution. If osseous reconstruction is planned, imaging of the donor site may be indicated, such as a CT angiogram of the lower extremities in the case of a free fibula flap or a CT angiogram of the chest if a scapula flap is to be used. If the maxilla or mandible is involved in the surgical plan, dental records are taken either in the form of stone casts, which are subsequently scanned, or digital impressions, which are combined with the CT face to create a composite 3-dimensional (3D) image with an accurate occlusion. Similarly, soft tissue can be modeled using a 3D camera, merging the soft tissue profile with the underlying skeletal information from the CT. Other modalities, such as MRI, can be merged to create a composite 3D image. Segmentation The next step is the process of segmentation, which is the delineation of structures of interest (eg, bone, nerve, vessels). In the past, this was done manually, selecting bone and soft tissue based on Hounsfield units. Today, this step is largely done by the planning software and can be fine-tuned by the engineer assisting in the treatment planning. Preoperative planning A meeting is then set up with the commercial vendor and takes place online with an engineer. This portion will of course be tailored to the specific case. If it is pathology, the lesion can be outlined and a margin established. If it is a trauma case, the fracture is identified. Bony cuts can then be simulated on the 3D model; the orientation of the cuts is evaluated in all 3 dimensions to ensure that structures, such as nerves and tooth roots, are avoided. If applicable, the unaffected contralateral side can be mirrored to demonstrate the proper reduction or bony contour. This is helpful in the context of trauma or in a secondary reduction, where the normal anatomy has been lost. Cutting guides are designed and can be tailored to the specific approach used and bone exposure anticipated. They should include a feature to register the guide to the bone. In the dentate portion of the maxilla or mandible, this may be an occlusal guide. Elsewhere, it may be a lip or tab that limits the degrees of freedom of the guide on the bone. Cutting guides can also incorporate predictive holes to predrill the screw holes used in the reconstruction plate. Predictive holes can obviate the need for intermaxillary fixation. If a reconstruction is planned using an osseous free flap, the graft is planned as well to fit the defect. If needed, osteotomies can be planned to contour the graft precisely to the space, which will be incorporated into the cutting guides. Dental rehabilitation can also be planned at this time. Endosseous implants can be incorporated into a fibula, for example, and their placement can be determined at this time. A temporary dental prosthesis can be made off of a stereolithic model. Hardware is then designed and is customized to the patient. In comparison to using stock plates, custom hardware offers great flexibility in terms of shape and screw hole placement. As with the cutting guides, nerves and tooth roots are avoided when designing the plate. The plans are finalized. Fabrication of models, plates, and guides Stereolithic models, cutting guides, and custom plates are manufactured. A number of benefits are realized by pre-manufacturing the hardware. For one, operative time can be reduced because the plates do not have be shaped intraoperatively. The hardware enjoys an excellent fit that is hard to replicate with hand bending. Furthermore, the strength of a reconstruction plate is higher than a bent plate because the custom milled plate does not incur the stress of bending. Everything is shipped to the hardware representative and is sterilized before surgery. Intraoperative registration If navigation is to be used, registration of the patient is performed before prepping and draping. This process will be unique to each navigation system, but generally involves the accurate orientation of the patient’s skull to the reference imaging in the navigation system using markers called fiducials. A variety of fiducials have been used, from implanted titanium markers, to dental splints, to light-emitting diode (LED)-containing masks. In some systems, a CT is obtained with the fiducial marker in place; for some systems this is not necessary. Intraoperatively, a headset is either anchored to the skull or attached to a mask that is in view of the navigation tower called the locator. An instrument is equipped with either reflectors or LED markers that can be visualized by the locator. The locator is used to identify points on the headset and other fiducials using the handheld instrument. The navigation system uses these points of reference to correlate the patient’s skull with the imaging. Surgery Surgery is then performed, using the appropriate approach for the surgical resection or to expose the fracture. If bone is to be resected, the cutting guides are fitted and secured with monocortical screws. Care must be taken to ensure that the cutting guide fits flush with the bone, and is not impeded by soft tissue. Predictive holes are then drilled, which will help maintain the occlusal relationship. The resection is performed. If an osseous flap is being harvested simultaneously, cutting guides are used for the bony flap as well. Implants are placed if applicable. The reconstruction plate can be fitted either to the facial defect, or if applicable, to the osseous free flap before transfer. With the pre-drilled holes, affixing the plate to bone is effortless. For a free flap, the pedicle is then divided and the flap inset. Intraoperatively, navigation will be used in a manner specific to the surgery. If it is an orbital floor fracture, for example, navigation may be used to confirm the seating of the reconstruction plate on the posterior ledge. For an orbital resection, navigation can be used to navigate the base of skull, or to guide osteotomies. Navigation is often used in conjunction with intraoperative CT or cone-beam CT to confirm an adequate reduction or appropriate reconstruction. Surgical applications Orbital reconstruction Periorbital trauma often results in an enlargement in the orbital volume. This can cause dystopia, enophthalmos, resulting in diplopia. It has historically been difficult to reestablish the pretraumatic orbital volume, complicated as it often is with posttraumatic swelling, limited access, and loss of bony landmarks. CAS provides a predictable approach to reconstructing the orbit. , If the contralateral orbit is unaffected, it can be mirrored and used to simulate the appropriate contours for the reconstructed orbit. A stereolithic model can be created from that simulation and an orbital reconstruction plate adapted to the defect. Custom plates can even be made, largely removing the guesswork of adapting the hardware. Intraoperative navigation can be used to both verify the correct positioning of the plate as well as to avoid critical structures at the orbital apex such as the optic nerve. Alternatively, intraoperative CT is useful to confirm the orbital repair. Orthognathic surgery CAS has transformed the work flow for planning orthognathic cases. Traditional model surgery is labor intensive and involves multiple steps; small errors made early on are magnified in the subsequent steps and can cause significant inaccuracy. Furthermore, complex asymmetries are challenging to model using traditional methods. With CAS, a fine-cut CT maxillofacial without contrast is obtained, as are dental models, either digital or digitized from plaster models. These are sent to a third-party vendor and melded together to create an accurate digital representation of the bony skeleton and dentition. Traditional orthognathic measurements and photos are taken as well and used in the analysis. A treatment planning session is arranged and the desired bony cuts are made and the movements simulated. A significant advantage to performing the surgery “virtually” is that bony interferences can be anticipated that can save time in the operating room. Occlusal splints are fabricated and custom cutting guides and plates can even be designed if desired. Temporomandibular joint surgery Severe temporomandibular joint disease is often treated with alloplastic reconstruction. Currently, reconstructive options for total joint replacement include stock and patient-specific prostheses. For a custom prosthesis, similar to an orthognathic surgery workup, a fine-cut CT maxillofacial without contrast and digitized dental models are merged. A prosthesis is then fabricated off of a stereolithic model by a third-party vendor. CAS allows complex planning; bilateral joint replacement and simultaneous orthognathic surgery can be reliably executed. Tumor resection CAS has applications in the resection of benign and malignant tumors in the head and neck. For odontogenic lesions, or lesions requiring a bony resection, the tumor can be delineated during the process of segmentation, and resection margins are determined during the planning session. Structures such as nerves, vessels, and teeth are identified and avoided if possible or included in the resection. Navigation also can be useful when resecting head and neck tumors. Some investigators have described the use of navigation to label resection margins. Frozen margins can be identified and marked using navigation. This can orient the pathologist and can aid in identifying areas that need to be re-resected. The labeled imaging also can be useful in communicating margin status with the radiation oncologist. Craniomaxillofacial reconstruction Pathology, trauma, and infection often result in bony defects that need to be reconstructed to restore form and function to the patient. Depending on the size and location of the defect, a bone graft is often required. Autogenous bone is the gold standard, and for larger defects, such as segmental defects of the mandible and maxillectomy defects, vascularized bone grafts are preferred for their reliability. Although the free fibula flap is the workhorse, scapula and vascularized iliac crest bone grafts are commonly used as well. CAS is of great use in planning the reconstruction. Cutting guides save operating room time by removing much of the measuring, shaping, and adjusting by essentially performing these steps virtually during the planning process. Fewer adjustments may mean reduced ischemia time, improving flap success. The more complicated the reconstruction is, the more useful CAS is in planning and executing the case. If appropriate, dental implants can be incorporated into the flap design. Implants placed primarily in a guided fashion shortens the time to prosthetic rehabilitation and improves the chance that the implants will be restorable. CAS also can be used to plan and construct patient-specific implants to address craniofacial deficiencies. These can be manufactured in titanium or polyetheretherketone and improve accuracy and efficiency of the reconstruction. Cases Patient KL Patient KL was a 33-year-old otherwise healthy woman with a 2-month history of swelling on the left side of her face with associated pain. Her examination was notable for expansion of the left maxilla. CT maxillofacial with contrast showed a mass in the left maxillary sinus with erosion of the lateral and superior walls ( Fig. 1 ). Fig. 1 CT maxillofacial with contrast. There is an expansile mass in the left maxilla extending medially through the lateral nasal wall, posteriorly into the infratemporal fossa, and superiorly into the orbit. The lesion was biopsied and was read as a hybrid odontogenic tumor. The case was planned using Virtual Surgical Planning (VSP). The outline of the tumor was delineated and the resection planned allowing a 1-cm margin. The patient was planned for a free fibula flap reconstruction. A stereolithic model of the planned reconstruction was fabricated and titanium midface plates were bent prior to surgery and sterilized ( Fig. 2 ). She was taken to the operating room. Before prepping and draping, the registration process was performed ( Fig. 3 ). Fig. 2 Stereolithic model with planned fibula reconstruction from frontal, 3/4s, superior, and inferior views. Titanium plates have been bent to adapt to the fibula segments. Fig. 3 Registration is performed before prepping and draping. This particular system uses a mask with multiple LEDs that are detected by cameras in the tower. The tower must be positioned so that the mask is fully visible. The LEDs will change color from red to green when visible by the tower. The navigation tool is then registered with the tower and accuracy is confirmed using known landmarks. A tracheostomy was first performed. The left maxilla was approached via a Weber-Ferguson incision. Dissection was started in a subperiosteal plane, and taken supraperiosteal over the tumor. A 5-mm cuff of normal mucosa was outlined along the tumor that had fungated through the socket of tooth #15. Once all bony margins were exposed intraorally and transorally, the custom-made cutting guides were applied along the piriform rim and cuts were made from the lateral nasal wall toward the medial infraorbital rim. Posteriorly, the cutting guide was applied along the zygomatic body and lateral cuts were made along the body of zygoma and extending posteriorly toward the pterygoid plates. Intraoral bone cuts were made along the hard palate. Osteotomy of the maxilla was completed with osteotomes, and after downward displacement of the maxilla, it was found that the mass was easily elevated off the surrounding sinus mucosa ( Fig. 4 ). Fig. 4 A Weber-Ferguson approach was used. The bony resection has been performed with the aid of custom cutting guides. The tumor was elevated circumferentially and position confirmed with intraoperative navigation. Bony cuts were made posteriorly to deliver the specimen with maxillectomy scissors and the specimen delivered en bloc ( Fig. 5 ). A left neck dissection was subsequently performed and the defect reconstructed with a free fibula flap ( Figs. 6 and 7 ). Fig. 5 Left maxillary specimen. Fig. 6 The fibula has been inset, using the pre-bent titanium plates. On the right, the Weber-Ferguson incision has been closed, and the fibula skin paddle closes the oral wound. Fig. 7 Postoperative CT maxillofacial without contrast demonstrating the restoration of volume in the left midface and symmetry of the soft tissue profile. Patient MO Patient MO was a 58-year-old woman with a cT4aN1M0 squamous cell carcinoma of the left maxillary sinus. Her past medical history was noncontributory. Her examination was notable for a large oroantral communication into the left maxillary vestibule, along with a visible friable mass in the left maxillary sinus ( Fig. 8 ). Fig. 8 Frontal, left lateral, and worm’s eye views of the patient. Examination is notable for left exophthalmos. MRI was notable for a left maxillary sinus mass with destruction of the left zygoma, gross involvement of the orbit, abnormal enhancement extending into the cavernous sinus, and foramen rotundum concerning for perineural spread ( Fig. 9 ). Fig. 9 Axial and coronal cut of an MRI showing a mass of the left maxillary sinus involving the left zygoma and orbit. There was no evidence of distant disease on PET/CT ( Fig. 10 ). The lesion was biopsied and returned invasive squamous cell carcinoma. She was planned for surgical extirpation and microvascular reconstruction using a scapular free flap with navigational assistance ( Figs. 11–14 ). Fig. 10 PET/CT redemonstrating the mass in the left maxillary sinus, extending into the left orbit. Fig. 11 The preoperative CT maxillofacial has been uploaded to the VSP system. The 3D reconstruction is shown. The destruction of the left maxilla is evident. Fig. 12 The lesion is outlined and the proposed cuts are made. The part to be resected is highlighted green. Fig. 13 The contralateral midface is mirrored. Fig. 14 The planned resection has been performed and the contralateral side is mirrored. This will be used with the navigation system at the time of surgery. DICOM, digital imaging and communication in medicine. After the patient was prepped and draped, a tracheostomy was performed. Next, using a #15 blade, a small incision was made 1 cm on the vertex of the scalp, carried down through periosteum. The Stryker navigation receiver was then mounted into the vertex of the skull using the applied 6-mm screw. The navigation system was then calibrated with a facemask placed on the patient's face and after adequate calibration, the face mask was removed. The left neck dissection was then performed, followed by the left maxillectomy. A marking pen was used to mark a Weber-Ferguson–type incision along the left maxillary region. This was carried to the inferior lid to encompass a paddle of skin including the inferior eyelid and surrounding periorbital skin approximately 3 × 3 cm, as this was tethered down to the underlying tumor and needed to be sacrificed from for thrombotic safety. The upper lid was preserved. The incision was then marked along the lash line of the upper lid to preserve as much upper eyelid skin as possible. This incision made with a #15 blade through skin and subcutaneous tissue. Electrocautery was used to develop a Weber-Ferguson skin flap. Care was taken to create a healthy and hearty flap without compromising oncologic stability. The skin flap was elevated from medial to lateral and mucosal incision in the left maxillary vestibule was completed with electrocautery to connect the intraoral and extraoral components of the skin flap. Next, a subperiosteal dissection of the superior orbital rim was completed with the periosteal elevator. This was then carried laterally to the level of the zygomatic arch. The incision was then connected from the extraoral to intraoral component using electrocautery down the midline of the anterior maxillary alveolus and hard palate and carried posteriorly to the posterior buccal vestibule ( Fig. 15 ). Fig. 15 A Weber-Ferguson approach is performed. A reciprocating saw was used to create the maxillary osteotomies as previously planned on medical modeling. Navigation was used to assist in recreating these osteotomies as planned ( Fig. 16 ). Fig. 16 Reciprocating saw is used with navigation guidance to complete the planned osteotomies. The reciprocating saw was used to prepare the palatal osteotomy, which was then carried to the piriform aperture and then along the lateral nasal skeleton toward the medial aspect of the orbital rim. The medial orbital rim was dissected subperiosteally and orbital contents were retracted and a medial orbital rim cut was made with the reciprocating saw. Next, attention was turned toward the lateral orbital wall. The orbital contents were reflected medially in the lateral aspect and the reciprocating saw was used to create an osteotomy on the lateral wall. Through the lateral orbital wall, as well as the lateral orbital rim, a tempero-zygomatic osteotomy was created with the reciprocating saw to free the remaining zygoma bone from its attachments. Finally, a maxillectomy was completed by using a curved Mayo scissor to disarticulate the pterygoid musculature from the pterygoid plates. The specimen was carefully teased out. The optic nerve and ophthalmic artery were identified and ligated. At this point, the specimen was removed as a left total maxillectomy with orbital exenteration ( Fig. 17 ). Fig. 17 The left hemi-maxillectomy has been performed along with the orbital exenteration. There appeared to be some questionable tissue left at the anterior skull base and this was resected using a combination of sharp dissection and curettage and sent for permanent pathology. Frozen sections from the specimen as well as the anterior skull base and lateral temporal region were sent, which were all negative for carcinoma ( Fig. 18 ). Fig. 18 The maxillectomy specimen as seen from the anterior and medial views. On the right is the left neck dissection. At this point, hemostasis was achieved with electrocautery. Simultaneously, the reconstructive surgeons were elevating a chimeric flap based on the circumflex scapular arterial system. The skin paddles were designed to be able to reconstruct the 3 portions of the planned defect, the oral cavity, the mucosa of the lateral nasal wall, and the external infraorbital skin ( Fig. 19 ). Fig. 19 Latissimus dorsi muscle is elevated along with a bilobed parascapular and scapular skin flap as well as 9 cm of scapula bone. A tunnel was created with a hemostat from the lateral pharyngeal space to the maxillary vestibule into the left neck just superficial to the carotid artery for microvascular anastomosis later in the case. Drill holes were created in the midline palate, 3 total as well as the remaining oral cavity, fourth level, for resuspension of the flap later in the case. The nasal septum was preserved ( Figs. 20 and 21 ). Fig. 20 The flap is inset and the skin closed. Fig. 21 Patient presented 6 months after surgery. She has a well-fitting implant-supported facial prosthesis. Patient TA Patient TA was a 68-year-old man with a cT3N2bM0 (National Comprehensive Cancer Network seventh edition staging) p16+ squamous cell carcinoma of the left posterior palate treated initially with chemotherapy and radiation ( Fig. 22 ). Fig. 22 Preoperatively, fullness is noted in the left maxilla. Progression was noted on a follow-up MRI extending into the left maxillary sinus and involving the zygoma, orbital contents, pterygoid fossa, and invasion of the base of skull. He subsequently underwent a salvage resection followed by gamma knife radiation and adjuvant chemotherapy. The case was planned using VSP ( Figs. 23–26 ). After being prepped and draped, a tracheostomy was performed, as was the left neck dissection ( Fig. 27 ). Fig. 23 The preoperative maxillofacial CT is uploaded to the VSP system. The 3D reconstruction is seen here. Fig. 24 The lesion is identified in the left maxilla and margins are determined. The portion to be resected is highlighted green. Fig. 25 The contralateral maxilla has been mirrored to reestablish symmetry. This virtual plan was uploaded to the navigation system to be used during surgery. Fig. 26 A stereolithic model was created. This model demonstrates the defect in the left anterior maxillary wall. Fig. 27 A tracheostomy was performed at the start of the case. Attention was then turned to the skin overlying the left mandible and chin and a notched incision was then made for esthetics down to the mandible and also the left intraoral vestibule. This dissection was then taken carefully to identify the left ventral nerve and then retracted and preserved. Next, an incision was made in a Weber-Ferguson approach of the face going through notching the vermilion border of the upper lip, up the columella, around the alar rim, up toward the medial canthus through the forehead and up toward the scalp, and with the left releasing incision in a hemi-coronal fashion ( Fig. 28 ). Fig. 28 The initial skin markings were made. A modified Weber-Ferguson and lip split were planned to allow generous exposure. A thick skin flap was made in the sub–superficial muscular aponeurotic system layer retracting the entire skin flap along a broad front posteriorly. Careful attention was made to preserve the tarsus of the eye and to preserve a skin muscle flap overlying the eyelids for closure. This was done by making a supraciliary and subciliary incision, preserving the tarsal plates for resection. A skin muscle flap was then taken over the septum with the septum and remaining orbital contents being left for the resection. An incision was then taken in the sub-pericranial plane along the scalp down to the superficial temporalis fascia to protect the temporal branch of the facial nerve. The temporoparietal layer was reflected off the superficial temporalis fascia down to the level of the zygomatic arch, where it was then sized to obtain access to the left zygomatic arch as well as the left orbital rim ( Fig. 29 ). A mandibulotomy was performed to improve access ( Fig. 30 ). Fig. 29 Wide exposure was obtained to allow access to the midface and orbit. Fig. 30 Mandibulotomy is performed to improve access to the parapharyngeal space. In concordance with the preoperative plan and computer planning, a sagittal saw was then used to make an osteotomy through the zygomatic arch as well as the left lateral orbital rim. This was then continued into maxillectomy osteotomy, which was taken mid-palatal up along the left lateral rim of the nose. The contents of Tenon capsule at the oral apex were then clamped bovied at the apex, releasing the orbital contents with the resection. The specimen, which included left maxilla, left orbit, and part of the left arch, and the tumor of the left malar eminence was then resected in total ( Figs. 31 and 32 ). Fig. 31 Following the VSP plan, the bony cuts are made in the left maxilla and zygoma and the left maxillectomy and orbital exenteration is completed. Fig. 32 Frontal, lateral, and superior views of the specimen. The neurosurgery team then entered the case and then proceeded with dissection and resection of the anterior cranial base and the intracranial component of the tumor ( Fig. 33 ). Following this, the reconstructive team harvested 7 cm of scapula along with latissimus dorsi muscle and a parascapular skin paddle were harvested and used to reconstruct the defect ( Fig. 34 ). Preformed titanium plates were used to position the scapula ( Figs. 35–39 ). Fig. 33 The navigation system was used to aid in establishing margins. Fig. 34 On the left, skin flaps have been elevated, exposing the latissimus dorsi. On the right, the composite flap includes latissimus dorsi muscle, 7 cm of scapula, and a skin paddle. Fig. 35 The scapula was inset to reconstruct the infraorbital rim and zygomatic projection. Fig. 36 The skin paddle was used to close the oral defect. Fig. 37 Incisions were closed with drains placed in the scalp and neck. Fig. 38 At 6 months, the surgical site was well healed. Fig. 39 There was some residual weakness of the left shoulder. Disclosure The authors have nothing to disclose. References 1. Ritschl L.M., Mücke T., Fichter A.M., et. al.: Axiographic results of CAD/CAM-assisted microvascular, fibular free flap reconstruction of the mandible: a prospective study of 21 consecutive cases. J Craniomaxillofac Surg 2017; 45: pp. 113-119. 2. 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