The Learning Curve of Computer-Assisted Free Flap Jaw Reconstruction Surgery Using 3D-Printed Patient-Specific Plates: A Cumulative Sum Analysis

Abstract

BackgroundComputer-assisted jaw reconstruction (CAJR) has benefits in reducing operation time and improving reconstruction accuracy, compared to conventional freehand jaw reconstruction. However, no information is available regarding learning curves in CAJR with the use of 3D-printed patient-specific surgical plates (PSSP). The purpose of this study was to assess surgical outcomes and learning curve for the first 58 consecutive CAJR using 3D-printed PSSP performed by a single surgical team in a single institution.MethodsIn a prospective study, consecutive patients who underwent free flap CAJR using 3D-printed PSSP were included. The determination of proficiency, based on the cumulative sum of surgical success (no major adjustment of 3D-printed PSSP, flap survival) passing the acceptable boundary line of cumulative sum analysis, was the primary outcome. To find out any potential factors influencing the learning curve, baseline characteristics of patients were compared before and after proficiency achievement. Secondary outcomes included inflexion points of the total operation time, blood loss, length of hospital stay, and bone graft deviation, measured by the cumulative sum analysis.ResultsFrom December 2016 to November 2020, 58 consecutive cases underwent surgery performed by a single surgical team. The overall surgical success rate was 94.8% (55/58). A three-stage learning curve of primary outcome was observed. The proficiency was achieved after 23 cases. The proportions of advanced tumor staging and concomitant surgery after obtaining proficiency were significantly higher than those before achieving proficiency (p = 0.046 and p < 0.001, respectively). Mean values of operation time, intraoperative blood loss, length of hospital stay, and bone graft deviation were 532.5 ± 119.2 min, 1,006.8 ± 547.2 ml, 16.1 ± 6.3 days, and 0.9 ± 1.2 mm, respectively. Two trends of learning curve were observed in the CUSUM analyses of total operation time, length of hospital stay, and bone graft deviation, in which the first and second inflexion points occurred between 8 and 17 cases and between 43 and 46 cases, respectively.ConclusionOur results revealed a three-stage learning curve of CAJR with the use of PSSP, including initial learning, plateau, and overlearning. Based on CUSUM analysis, the surgical proficiency was achieved after 23 cases, and total operation time, length of hospital stay, and bone graft deviation stabilized after 8–17 cases.

Value of 3D printing technology combined with indocyanine green fluorescent navigation in complex laparoscopic hepatectomy

“…All final pathological microscopic R0 margins were negative in 3DP group, while two were positive in the non-3DP group. 3D printing has been widely applied to plastic and reconstructive surgeries with good clinical effects [25][26][27]. However, the effects and value of applying 3D printing to LH have rarely been reported on and are relatively uncertain, especially due to the lengthy time and high cost required to produce liver models [28,29].…”

Superficial Temporal Artery and Vein as Alternative Recipient Vessels for Intraoral Reconstruction With Free Flaps to Avoid the Cervical Approach With the Resulting Need for Double Flap Transfer in Previously Treated Necks

“…For this reason, intraoral resection and vessel preparation as well as flap raising and reconstruction were performed by senior consultants of our clinic. Nevertheless, the influence of surgical experience by varying surgeons cannot be ruled out in this university hospital setting as well as in this retrospective study ( 37 , 38 ). According to recent CUSUM analyses by Han et al.…”

“…According to recent CUSUM analyses by Han et al. and Zhu et al., the learning curve in microsurgical reconstruction or mandibular reconstruction stabilizes after 20 or 8–17 cases ( 38 , 39 ). However, the bony reconstruction was always well manageable by the operating senior consultant with the use of angled tools and pre-bent mini-osteosynthesis plates.…”

Surgical Margins After Computer-Assisted Mandibular Reconstruction: A Retrospective Study

“…Techniques described in this article may be considered a valuable aid in the planning of composite flaps using virtual surgery, nevertheless the use of this technology requires a learning curve [ 30 ] in order to make the most of the potential and benefits of the method and at the same time to obtain free bone margins.…”