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Virtual Surgical Planning in Free Fibula Reconstruction of the Head and Neck Region: Comparison of Surgical Outcomes with the Conventional Technique
Fuat Baris Bengur, MD; Erin Anstadt, MD; Rakan Saadoun, MD; Nayel Khan, MD; Elizabeth A. Moroni, MD, MHA; Shaum Sridharan, MD; Mark Kubik, MD; Mario G. Solari, MD
University of Pittsburgh, Department of Plastic Surgery

Background: Pre-operative virtual surgical planning (VSP) through computer-aided design and computer-aided modeling (CAD/CAM) is an emerging technology that revolutionized the way we approach head and neck reconstruction after extirpative surgery. Given the relatively recent introduction, studies performing head-to-head comparison to the conventional technique are limited. We aimed to compare free fibular reconstructions of the head and neck reconstructions with VSP versus the conventional technique for early surgical outcomes to elucidate the clinical impact of VSP.
Methods: A retrospective review of the patients who underwent head and neck free flap reconstruction at a tertiary center from 2012 to 2021 was performed. All free fibular reconstructions were included regardless of the etiology. Data regarding patient demographics, past medical history, surgical details, and overall outcomes was collected. Patients that had VSP were compared with the patients who underwent reconstruction with the conventional technique. Outcomes studied included postoperative 30-day recipient site complications, total and partial flap failure, and hardware exposure rates. Statistical analysis was performed using chi-square and T-tests, and P-value ≤ 0.05 was considered statistically significant.
Results: Free fibular reconstructions were performed in 273 patients. VSP (n=173) and conventional (n=100) cohorts had similar characteristics in terms of gender (male 64% vs 68%, p=0.520), BMI (266vs266, p=0.898), and tobacco use (smokers 72% vs 81%, p=0.106). The VSP cohort was younger than the conventional counterpart (5813vs6111, p=0.033), had more vascular comorbidities (8% vs 1%, p=0.019) and had higher rates of previous radiotherapy history (14% vs 7%, p=0.085). The operative duration was significantly shorter with the use of VSP (724153vs784169, p=0.003), while the ischemia times were similar (13732vs13151, p=0.365). Both groups had similar rates of total (2% vs 2%, p=0.875) and partial (4% vs 4%, p=0.985) flap loss, recipient site dehiscence (11% vs 15%, p=0.333), infection (23% vs 15%, p=0.132) and hematoma (5% vs 2%, p=0.266). The VSP group had significantly lower rates of hardware (2% vs 8%, p=0.011) and bone exposure (1% vs 5%, p=0.053) on the postoperative 30-day period.
Conclusion: This is the largest study to compare outcomes between VSP with the conventional technique for bony reconstruction of the head and neck region. Our results show that the use of VSP has reduced the operative duration. Early surgical complication rates are similar to the conventional technique, while the hardware exposure rates are significantly lower. Longer follow-up of our cohort will provide an in-depth understanding on the benefits of VSP for head and neck reconstruction.


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