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The Use of Three-Dimensional Digital Technology and Additive Manufacturing to Create Templates for Soft-Tissue Reconstruction

Lindsay, Robin W. M.D.; Herberg, Matthew M.D.; Liacouras, Peter Ph.D.

Plastic and Reconstructive Surgery: October 2012 - Volume 130 - Issue 4 - p 630e–632e
doi: 10.1097/PRS.0b013e318262f509
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Department of Otolaryngology, Head and Neck Surgery, National Military Medical Center, and, Uniformed Services University of the Health Sciences

Department of Otolaryngology, Head and Neck Surgery, National Military Medical Center

3D Medical Applications Center, National Military Medical Center, Bethesda, Md.

Correspondence to Dr. Lindsay, National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Md. 20889 robinwlindsay@gmail.com

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Sir:

Reconstructive decision making is based on many factors; however, regardless of the technique used, the goal is the same—to create facial symmetry. Surgeons must ensure not only that lost facial volume is restored but also that facial symmetry is reestablished. Decisions can be impeded by the two-dimensional nature of standard photography and by intraoperative facial edema making accurate operative volume calculations problematic. An ideal approach would calculate the deficient volume preoperatively and create a spatial model or “template.”

We describe the use of digital technology and additive manufacturing for preoperative soft-tissue defect assessment and surgical repair. Soft-tissue contours of the patient were captured using the 3dMDcranial system (3dMD, Atlanta, Ga.) (Fig. 1, left). A mirror image model was then produced and aligned with the original model. The section corresponding to the deficient part of the face was digitally cut out and saved as a separate piece (graft template). All transition borders were then smoothed with FreeForm Modeling Plus Software (SensAble Technologies, Woburn, Mass.) to create an “ideal face” (Fig. 1, center). Overlapping was removed between the graft template and original face (Boolean operation). Scaling was performed to account for tissue reabsorption (25 percent was anticipated for the dermal fat graft). The original face and graft templates were then saved as STL files and processed on a build platform using Light Year (3D Systems, Rock Hill, S.C.). The files were then rapid prototyped using a stereolithography apparatus. The templates were molded and made from polymethyl methacrylate. This provided the surgeon with an exact volume-scaled three-dimensional template from which to appropriately fashion and position the dermal fat graft (Fig. 2).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Using three-dimensional applications for reconstruction of the craniofacial skeleton has improved the planning, timing, and precision for microvascular and posttraumatic craniomaxillofacial reconstruction1; however, using three-dimensional applications for soft-tissue reconstruction has not been described previously. Previously, templates were fabricated using x-ray film or suture packaging, which do not provide three-dimensional volume or precise positioning.

The current technique is in its infancy, but patient satisfaction has been good. Volume calculations were performed for the patient depicted in Figs. 1 and 2. The defect was 6500 mm3 and the volume increase postoperatively was 9622 mm3, representing an overcorrection of 32 percent, which is close to the 25 percent that was our target, anticipating that amount of dermal fat graft absorption. Previous studies have used subjective rating scales to evaluate outcomes or required patients to have repeated computed topographic imaging to calculate postoperative volume changes.2-4

This approach facilitates surgical planning and could potentially decrease operative time and improve facial symmetry. Furthermore, postoperative volume restoration and symmetry can be accurately and rigorously quantified. In the future, this technique will be used consistently to quantitatively evaluate the symmetry achieved in soft-tissue reconstruction. In the current era, we should be moving toward using the three-dimensional applications currently available to push the limits of reconstructive possibilities and to quantitatively evaluate surgical outcomes.

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PATIENT CONSENT

The patient provided written consent for use of her images.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Robin W. Lindsay, M.D.

Department of Otolaryngology, Head and Neck Surgery

National Military Medical Center, and

Uniformed Services University of the Health Sciences

Matthew Herberg, M.D.

Department of Otolaryngology, Head and Neck Surgery

National Military Medical Center

Peter Liacouras, Ph.D.

3D Medical Applications Center

National Military Medical Center

Bethesda, Md.

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REFERENCES

1. Tepper OM, Sorice S, Hershman GN, Saadeh P, Levine JP, Hirsch D. Use of virtual 3-dimensional surgery in post-traumatic craniomaxillofacial reconstruction. J Oral Maxillofac Surg.. 2011;69:733–741
2. Mendelson BC, Jacobson SR, Lavoipierre AM, Huggins RJ. The fate of porous hydroxyapatite granules used in facial skeletal augmentation. Aesthetic Plast Surg.. 2010;34:455–461
3. Matic DB, Kim S. Temporal hollowing following coronal incision: A prospective, randomized, controlled trial. Plast Reconstr Surg.. 2008;121:379e–385e
4. Jin X, Teng L, Xu J. Anterolateral thigh adipofascial flap for the restoration of facial contour deformities. Microsurgery. 2010;30:368–375
©2012American Society of Plastic Surgeons