A Multi-Center Experience with Image-Guided Surgical Navigation In Complex Craniomaxillofacial Surgery: Should It Be the New Standard of Care?

Purpose:  Image-guided surgical navigation, or CT-guided surgery, is a technology used by many specialties to reduce complications and improve surgical outcomes. Its use has become standard of care for intracranial procedures in Neurosurgery as well as sinus and skull base surgeries performed by Otolaryngologists.  The authors hypothesize that image-guided surgical navigation has a wide scope of utility in many craniomaxillofacial procedures.  With time and experience, its use will reduce peri-operative complications and should become standard of care in many craniomaxillofacial reconstructions.

Methods:  A multi-center (University of California- Los Angeles, New York University, and the University of Kansas Medical Center) retrospective review was performed. All craniomaxillofacial procedures utilizing image-guided surgical navigation were included over a ten year period.  A chart review obtained patient demographics, diagnosis, surgical procedure, and post-operative course.   Intra-operatively, the accuracy of the image-guided navigation was evaluated by comparing surgically visualized landmarks to those reported by the navigation system. 

Results:  Twenty-three patients were identified who underwent a total of 31 CT-guided navigation procedures involving upper (n=3), middle (n=12), and lower (n=6) facial reconstructions.  Navigation was also utilized in reconstruction of multiple facial zones (n=2).  Upper facial reconstruction procedures included a skull base surgery and two cases of frontal sinus/forehead reconstruction.  Mid-facial procedures included 8 orbit fracture reconstructions (two bilateral), two cases of bilateral orbit and midface reconstruction for Treacher Collins syndrome (4 lateral orbit and zygomatic arch constructions), one case of enophthalmus repair after meningioma resection involving the orbit floor and lateral wall, and one case of orbital neurofibroma excision and orbital box osteotomy. Lower facial procedures entailed four cases of bilateral temporomandibular joint (TMJ) bony ankylosis release (8 TMJs) and two cases of condylar reconstruction in mandibular hypoplasia.  Imaged-guided surgical navigation was used for pan-facial reconstruction in 2 cases.  In all 31 procedures, the image-guided system correctly identified the surgical anatomy to less than 2 mm.  Follow-up demonstrated no complications associated with any procedure and no revisionary procedures were required to date.

Conclusion: CT-guided navigation is a safe and effective tool with multiple applications in craniomaxillofacial surgery. Further experience will expand its clinical utility in craniofacial surgery.  With time, its utilization should become standard of care in selected complex craniofacial procedures.