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Stereolithographic Modeling in Reconstructive Surgery of the Craniofacial Skeleton after Tumor Resection

Chopra, Karan M.D.; Gastman, Brian R. M.D.; Manson, Paul N. M.D.

Author Information
Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 743e-745e
doi: 10.1097/PRS.0b013e318245e765
Erratum

In the Viewpoint article by Chopra et al. entitled “Stereolithographic Modeling in Reconstructive Surgery of the Craniofacial Skeleton after Tumor Resection,” published in the April 2012 issue of the ( 2012;129:743e–745e), the order of the authors' names is incorrect. The correct order is as follows: Karan Chopra, M.D., Paul N. Manson, M.D., and Brian R. Gastman, M.D.

Plastic and Reconstructive Surgery. 130(1):262, July 2012.

Sir:

Figure
Figure

The complex anatomy of the head and neck presents unique challenges to reconstructive surgeons. However, an innovative medical imaging modality, stereolithographic modeling, allows fabrication of detailed models from computed tomographic images. Surgeons can use these to clearly visualize otherwise elusive anatomical details in surgical patients.1 Reports of stereolithographic modeling in plastic and reconstructive surgery are currently limited as applied to surgical reconstruction of large-scale tumor defects of the head and neck. Reports in other fields, such as otolaryngology and oral surgery, focus on cancer extirpation planning and reconstruction of nonmalignant defects.25 However, certain surgical scenarios in plastic and reconstructive surgery lend themselves very well to this technology.

One such scenario is a unilateral defect in which the unaffected side of the skeletal structure is used to estimate the size, shape, and placement of bone fragments, osteotomized bone grafts, and contoured titanium plates. This is often an imprecise science, for which intraoperative visual approximation suffices. However, restoration of functional anatomy such as occlusal surfaces, the temporomandibular joint, and orbital walls demands precise plate bending. One author (B.R.G.) has used this technology in approximately 25 percent of more than 100 cases involving bony reconstruction for postextirpative defects. It is in these reconstructions that stereolithography provides a distinct advantage, allowing the surgeon an opportunity to improve the reconstruction by (1) enhanced planning of the procedure before entering the operating room, (2) more accurately bending of plates to the patient's own anatomy, and (3) improved patient and trainee/assistant education through three-dimensional hands-on models. The authors present one such case that highlights the advantages.

A 55-year-old man presented with a tumor of the oromandibular region following subtotal mandibulectomy for tumor resection. Defects requiring reconstruction included the left oral tongue, subtotal mandibulectomy from the left condyle to the right mental foramen, and the left mental and premandibular skin. Mirror image reflection of the unaffected jaw across the midline generated a “perfect” model with the desired mandible anatomy (Fig. 1). Traditionally, tumor extending to the external surface of the mandible precluded preplating. However, use of the stereolithographic model allowed plate bending well before the extirpation was complete. Other benefits included optimal jaw function (Fig. 2), reasonable aesthetic result, and reduced ischemia time because osteotomies of the fibula were performed during harvest of the flap.

Fig. 1
Fig. 1:
Stereolithographic model created by virtual mirror imaging of the contralateral side with titanium plates prebent by the surgeon.
Fig. 2
Fig. 2:
Patient follow-up with reconstruction completed. The patient showed marked improvement in his ability to open and close his mouth.

We recognize that stereolithographic modeling is not appropriate for every reconstructive case because of added cost and potential delays in treatment (although production can be expedited to less than 7 days). However, the visibility of defects and deformities in the head and neck, and the presence of specialized dynamic structures (e.g., temporomandibular joint) and anatomy that support functional tissues (e.g., the bony orbit), demand advanced surgical reconstructive techniques. In this regard, stereolithographic modeling provides a unique planning platform for accurate reconstruction of these challenging defects. Thus, stereolithographic modeling technology presents a useful addition to the surgeon for reconstructing complex defects of the craniofacial skeleton.

Karan Chopra, M.D.

Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, Md.

Brian R. Gastman M.D.

Dermatology and Plastic Surgery Institute, Department of Plastic Surgery, Taussig Cancer Center, Lerner Research Institute, and, Department of Immunology, Head and Neck Institute, Cleveland, Ohio

Paul N. Manson, M.D.

Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Md.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

PATIENT CONSENT

The patient provided written consent for the use of his images.

ACKNOWLEDGMENT

The authors thank Marla K. Friedman, M.S.J.

REFERENCES

1. Barker TM, Earwaker WJ, Lisle DA. Accuracy of stereolithographic models of human anatomy. Australas Radiol. 1994;38:106–111.
2. Cunningham LL Jr, Madsen MJ, Peterson G. Stereolithographic modeling technology applied to tumor resection. J Oral Maxillofac Surg. 2005;63:873–878.
3. Bell RB, Markiewicz MR. Computer-assisted planning, stereolithographic modeling, and intraoperative navigation for complex orbital reconstruction: A descriptive study in a preliminary cohort. J Oral Maxillofac Surg. 2009;67:2559–2570.
4. Ro EY, Ridge JA, Topham NS. Using stereolithographic models to plan mandibular reconstruction for advanced oral cavity cancer. Laryngoscope 2007;117:759–761.
5. Al-Sukhun J, Törnwall J, Lindqvist C, Kontio R, Penttila H. One-stage zygomaticomandibular approach for improved access to the hemimaxilla and the middle base of the skull. J Craniofac Surg. 2008;19:528–533.

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Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

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