Preliminary Development of a Workstation for Craniomaxillofacial Surgical Procedures: Introducing a Computer-Assisted Planning and Execution System

IntroductionFacial 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 and other related craniomaxillofacial procedures. MethodsWe 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. ResultsPlastic 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. ConclusionsThe initial development of the CAPE workstation demonstrated that 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 for numerous types of craniofacial and orthognathic surgical procedures.

[1]  Can Ozturk,et al.  An Update on Facial Transplantation Cases Performed between 2005 and 2010 , 2011, Plastic and reconstructive surgery.

[2]  C. Torrens.  Computer Assisted Orthopaedic Surgery , 2008, International Journal of Computer Assisted Radiology and Surgery.

[3]  Russell H. Taylor,et al.  Augmentation of human precision in computer-integrated surgery , 1992 .

[4]  Anuja K. Antony,et al.  Use of Virtual Surgery and Stereolithography-Guided Osteotomy for Mandibular Reconstruction with the Free Fibula , 2011, Plastic and reconstructive surgery.

[5]  E. Rodriguez,et al.  Total Face, Double Jaw, and Tongue Transplant Simulation: A Cadaveric Study Using Computer-Assisted Techniques , 2012, Plastic and reconstructive surgery.

[6]  Leonard B Kaban,et al.  Le Fort–Based Maxillofacial Transplantation: Current State of the Art and a Refined Technique Using Orthognathic Applications , 2012, The Journal of craniofacial surgery.

[7]  Anke Schmid,et al.  Standard Handbook Of Biomedical Engineering And Design , 2016 .

[8]  Leonard B Kaban,et al.  Osteocutaneous Maxillofacial Allotransplantation: Lessons Learned from a Novel Cadaver Study Applying Orthognathic Principles and Practice , 2011, Plastic and reconstructive surgery.

[9]  E. Rodriguez,et al.  Total Face, Double Jaw, and Tongue Transplantation: An Evolutionary Concept , 2013, Plastic and reconstructive surgery.

[10]  R. Bell,et al.  Computer planning and intraoperative navigation in cranio-maxillofacial surgery. , 2010, Oral and maxillofacial surgery clinics of North America.

[11]  Risal Djohan,et al.  First U.S. Near-Total Human Face Transplantation: A Paradigm Shift for Massive Complex Injuries , 2010, Plastic and reconstructive surgery.

[12]  F L Bookstein,et al.  Three‐Dimensional Computer‐Assisted Design of Craniofacial Surgical Procedures: Optimization and Interaction with Cephalometric and CT‐Based Models , 1986, Plastic and reconstructive surgery.

[13]  K. Cleary,et al.  Image-guided interventions: technology review and clinical applications. , 2010, Annual review of biomedical engineering.

[14]  P. Cinquin,et al.  IGOR: image guided operating robot , 1991, Fifth International Conference on Advanced Robotics 'Robots in Unstructured Environments.

[15]  Ryan J. Murphy,et al.  Establishing Cephalometric Landmarks for the Translational Study of Le Fort–Based Facial Transplantation in Swine: Enhanced Applications Using Computer-Assisted Surgery and Custom Cutting Guides , 2014, Plastic and reconstructive surgery.

[16]  Russell H. Taylor,et al.  Medical robotics in computer-integrated surgery , 2003, IEEE Trans. Robotics Autom..

[17]  Russell H. Taylor,et al.  Computer-Aided Orthopedic Surgery with Near-Real-Time Biomechanical Feedback , 2004 .

[18]  Brett A Miles,et al.  Stereolithography for craniofacial surgery. , 2006, The Journal of craniofacial surgery.

[19]  Leo Joskowicz,et al.  Computer-Integrated Surgery and Medical Robotics , 2002 .

[20]  Seenu M. Susarla,et al.  Le Fort‐based Maxillofacial Vascularized Transplantation , 2016 .

[21]  Anthony M. DiGioia,et al.  An Integrated Approach to Medical Robotics and Computer Assisted Surgery in Orthopaedics , 1995 .

[22]  Three patients with full facial transplantation. , 2012, The New England journal of medicine.

[23]  Mehran Armand,et al.  Periacetabular osteotomy in adult hip dysplasia - developing a computer aided real-time biomechanical guiding system (BGS). , 2008, Suomen ortopedia ja traumatologia = Ortopedi och traumatologi i Finland = Finnish journal of orthopaedics and traumatology.

[24]  Liana Puscas,et al.  Computer modeling and navigation in maxillofacial surgery , 2009, Current opinion in otolaryngology & head and neck surgery.

[25]  Ryan J. Murphy,et al.  Overcoming Cross-Gender Differences and Challenges in Le Fort–Based, Craniomaxillofacial Transplantation With Enhanced Computer-Assisted Technology , 2013, Annals of plastic surgery.

[26]  J. Xia,et al.  Prototype testing for a new bioabsorbable Le Fort III distraction device: a pilot study. , 2004, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons.

[27]  B. Pomahac,et al.  The Brigham and Women's Hospital face transplant program: a look back. , 2012, Plastic and reconstructive surgery.

[28]  J. Glowacki,et al.  A minipig model of maxillary distraction osteogenesis. , 2010, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons.

[29]  P. Mehra,et al.  Use of 3-D Stereolithographic Models in Oral and Maxillofacial Surgery , 2011, Journal of maxillofacial and oral surgery.

[30]  S. Schneeberger,et al.  The World's Experience With Facial Transplantation: What Have We Learned Thus Far? , 2009, Annals of plastic surgery.