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Surgeons use computer-aided design and modeling (CAD/CAM) for fibula flap reconstruction to achieve optimized results. We developed a protocol combing CAD/CAM with computed tomography angiography (CTA) to map peroneal artery perforators to center the skin island. We hypothesized that CAD/CAM+CTA would decrease operative times and improve patient outcomes with respect to fewer surgical site occurrences and lesser need for revisional surgeries.
Materials and Methods:
We retrospectively compared consecutive patients (N=159) at a single major US cancer center who underwent mandibulectomy reconstruction with free fibula flaps for whom CAD/CAM+CTA (N=38), CTA-only (N=64), or neither technology (N=57) were employed preoperatively over a seven-year period (2008-2015). To minimize selection bias, we only included patients of surgeons who selectively employed both CAD/CAM+CTA as well as conventional fibula flap harvest with or without CTA in the study. We employed logistic regression analysis to identify potential associations between patient and reconstructive factors and postoperative outcomes.
Results:
Patient characteristics were similar between the three groups. The number of fibular osteotomies was significantly higher in the CAD/CAM+CTA group versus both the CTA-only group and the conventional fibula group (1.4 vs 1.0 vs. 1.0; p=0.02). Flap ischemia time was significantly shorter in both the CAD/CAM+CTA group and the CTA-only group vs. the conventional fibula group (80 vs. 87 vs. 121 minutes; p<0.01), while total operative time was similar between the three groups (616 vs. 641 vs. 646 minutes; p=0.56). Average length of hospital stay was similar, but ICU stay was significantly shorter in both the CAD/CAM+CTA group and the CTA-only group vs. the conventional fibula group (2.1 vs. 2.1 vs. 7.6 days; p<0.01). Surgical complication rates, including flap failure rates, were similar between groups (p=0.49). However, anastomostic thrombosis rates were higher in the conventional fibula group than in the other two groups (p=0.01). There was a trend towards less need for surgical revision for contour deformity and asymmetry in the CAD/CAM+CTA group vs. the other two groups that did not reach statistical significance (7.9 % vs. 23.4% vs. 17.5%, respectively; p=0.14).
Conclusions:
There appear to be advantages for preoperative planning combining the use of CAD/CAM and CTA for mandibular reconstruction with free fibula flaps. Specifically this strategy appears to facilitate more complex reconstructions, shorter ischemia times, shorter ICU stays, and improved postoperative outcomes.