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Original Investigation
April 1, 2021

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
  • 2Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida
  • 3Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
  • 4Department of Radiology, Mayo Clinic, Rochester, Minnesota
  • 5Department of Anatomic Modeling, Mayo Clinic, Rochester, Minnesota
JAMA Otolaryngol Head Neck Surg. Published online April 1, 2021. doi:10.1001/jamaoto.2021.0251
Key Points

Question  Does the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling decrease the need for external incisions in maxillectomy reconstruction?

Findings  This retrospective cohort study of 38 patients who underwent maxillectomies requiring microvascular reconstruction compares one group of patients from an era prior to VSP with one group from an era using VSP and 3-D modeling to design, contour, and inset the reconstructive flap. The patients in the VSP group had a very low rate of lateral rhinotomy despite having equally extensive defects as the patients in the pre-VSP group.

Meaning  This study suggests that VSP may help with planning, execution, placement, and fixation for complex free flap maxillectomy defect reconstruction through a transoral minimally invasive approach.


Importance  Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach.

Objective  To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction.

Design, Setting, and Participants  This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019.

Interventions  Maxillectomy and free flap reconstruction with or without VSP.

Main Outcomes and Measures  Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications.

Results  Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR.

Conclusions and Relevance  This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

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