It was a pleasure to read the article by Kamali et al.1 entitled, “The Current Role of Three-Dimensional Printing in Plastic Surgery.” The authors thoughtfully explain the process of using digital files to construct three-dimensional objects (a mystery to many surgeons) and describe current and future applications of three-dimensional printing in health care. As the article illustrates, the benefits of three-dimensional printing technology are many. The practical question plastic surgeons often have is, How can I start incorporating three-dimensional printing into my practice? Using three-dimensionally printed models for presurgical planning2 and implant prefabrication3 is currently the most common application. Models were historically obtained from vendors, but with increasing availability and affordability of the technology, more individuals and institutions now possess the capability to three-dimensionally print models on site. The authors point out that rudimentary three-dimensional printers cost as little as $300; so why are not all surgeons using this technology daily? In reality, the quality of printers and materials required to rapidly construct highly accurate models for medical use may entail expert-guided segmentation of good quality imaging data and be potentially more expensive, if submillimeter model accuracy is desired. Having said this, the up-front cost and effort should not dissuade us from using them. The following case illustrates the benefits of on-site, highly accurate three-dimensional printing and why it is currently an important tool in plastic surgery practice.
A 5-year-old girl was mauled by a pit bull, partially degloving the midface and lower lid, and causing comminuted fractures of the zygomaticomaxillary complex, orbit, and mandible. After the patient was medically stabilized, washout, soft-tissue repair, and mandibular fixation were performed; however, zygomatic and orbital fixation was postponed because of massive edema. It became clear the swelling would not expeditiously resolve, complicating open reduction and internal fixation. To address this, the surgeon collaborated with the radiologist and simulation center engineering staff to construct two computed tomography–derived three-dimensionally printed models in less than 15 hours. Hardware was prebent so that bone fragments could be adapted to the contoured plates, rather than struggling to align mobile fragments and bend plates in vivo. Working with the model preoperatively also revealed a 12-mm zygomaticomaxillary buttress gap not appreciated on digital imaging, and the plan was modified to include a bone graft. The operation was executed smoothly and successfully despite the challenging soft-tissue envelope (Fig. 1).
At our institution, on-site three-dimensional printing is currently performed as part of a larger, multidisciplinary simulation program with collaborators in engineering, radiology, surgery, critical care, and more. This collaboration facilitates exchange of ideas unlocking the true potential of three-dimensional printing in health care. In the case of the patient described above, three-dimensional printing using this on-site program had at least three direct benefits:
1. Increased ease of the procedure and presumably decreased operative time.
2. Improved precision of fixation and elucidation of anatomical findings (bone gap) not previously appreciated.
3. Faster time to surgery with in-house printed model (<1 day production time) compared with a commercial model.
The availability of an on-site program broadens the application of three-dimensional printing to trauma, and the benefits seen in this case all have the potential to decrease cost: decreasing operative time, reducing potential need for revision surgery, and faster time to the operating room mean a shorter inpatient stay and optimized healing. We appreciate Kamali et al. for initiating the discussion about three-dimensional printing in plastic surgery. Although their emphasis was on future applications, we continue the dialogue by shifting emphasis to the fact that this technology is currently available in many institutions and can improve your practice today. Furthermore, working with collaborators in other disciplines will increase the sophistication of how you use three-dimensional printing to improve your surgical practice.
This case presented in this Letter was presented at the 73rd Annual Meeting of the American Cleft Palate-Craniofacial AQ1 Association, in Atlanta, Georgia, April 4 through 9, 2016.
The authors have no financial interest in any of the products or devices mentioned in this communication.
Carolyn R. Rogers-Vizena, M.D.
Department of Plastic and Oral Surgery
Boston Children’s Hospital, and Harvard Medical School
Peter Weinstock, M.D., Ph.D.
Harvard Medical School
Department of Anesthesia,
Perioperative, and Pain Medicine
Division of Critical Care Medicine
Boston Children’s Hospital
Katie Livingston, B.S., M.E.
Boston Children’s Hospital
Sanjay P. Prabhu, M.B.B.S.
Harvard Medical School
Department of Radiology
Boston Children’s Hospital
1. Kamali P, Dean D, Skoracki R, et alThe current role of three-dimensional printing in plastic surgery.Plast Reconstr Surg20161371045–1055
2. Chopra K, Folstein MK, Manson PN, Gastman BRComplex craniofacial reconstruction using stereolithographic modeling.Ann Plast Surg20147259–63
3. Azuma M, Yanagawa T, Ishibashi-Kanno N, et alMandibular reconstruction using plates prebent to fit rapid prototyping 3-dimensional printing models ameliorates contour deformity.Head Face Med20141045
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