Preliminary Development of a Workstation for Craniomaxillofacial Surgical Procedures

Abstract

Introduction Facial transplantation represents one of the most complicated scenarios in craniofacial surgery because of skeletal, aesthetic, and dental discrepancies between donor and recipient. However, standard off-the-shelf vendor computer-assisted surgery systems may not provide custom features to mitigate the increased complexity of this particular procedure. We propose to develop a computer-assisted surgery solution customized for preoperative planning, intraoperative navigation including cutting guides, and dynamic, instantaneous feedback of cephalometric measurements/angles as needed for facial transplantation. Methods We developed the Computer-Assisted Planning and Execution (CAPE) workstation to assist with planning and execution of facial transplantation. Preoperative maxillofacial computed tomography (CT) scans were obtained on 4 size-mismatched miniature swine encompassing 2 live face-jaw-teeth transplants. The system was tested in a laboratory setting using plastic models of mismatched swine, after which the system was used in 2 live swine transplants. Postoperative CT imaging was obtained and compared with the preoperative plan and intraoperative measures from the CAPE workstation for both transplants. Results Plastic model tests familiarized the team with the CAPE workstation and identified several defects in the workflow. Live swine surgeries demonstrated utility of the CAPE system in the operating room, showing submillimeter registration error of 0.6 ± 0.24 mm and promising qualitative comparisons between intraoperative data and postoperative CT imaging. Conclusions The initial development of the CAPE workstation demonstrated integration of computer planning and intraoperative navigation for facial transplantation are possible with submillimeter accuracy. This approach can potentially improve preoperative planning, allowing ideal donor-recipient matching despite significant size mismatch, and accurate surgical execution.

Ancillary Procedures Necessary for Translational Research in Experimental Craniomaxillofacial Surgery

“…Following several swine cadaver/plastic model surgeries (n = 5), three live surgeries were completed to assist our engineering colleagues in developing a novel Computer-assisted Planning and Execution (CAPE) system. All major dental, skeletal and aesthetic inconsistencies were overcome using the technology in light of a major size mismatch between donor and recipient (4-6). However, all three face-jaw-teeth transplant recipients suffered premature death related to ancillary procedures - thereby demonstrating the need for further research.…”

“…As expected, the face-jaw-teeth alloflap demonstrated gravity-related venous congestion. Efforts surrounding computer-assisted surgery and cutting guide modifications helped to improve reconstructive outcomes in both the second and third live surgeries (4-6) [Figure 2]. In summary, all three peri-operative complications (i.e.…”

“…However, in order for surgeons and biomedical engineers to collaborate, develop, and enhance futuristic modalities related to computer-assisted technology, larger-scale anatomy is required. Therefore, researchers looking to improve outcomes in craniofacial surgery should be encouraged to first assess safety and reliability of new techniques in large animal laboratories (4-6) [Figure 12]. …”

“…As such, large animal studies often serve as the ideal vehicle for scientists and engineers testing novel concepts and techniques (4,5). Unfortunately, translational research in large animals has been tempered by unfamiliar facial skeletal anatomy coupled with the vital functions affected by orthotopic facial transplant research including breathing, drinking, and feeding (6).…”

Commentary on “A Multicenter Experience With Image-Guided Surgical Navigation

“…2). 3 The planning modules should help the surgeon set measurable goals, and at the same time, deliver immediate visual feedback. The intraoperative navigation system ought to ''guide'' the surgeon through the desirable paths-while helping to also identify/avoid critical regions and substrates (eg, highlight nerves and arteries).…”