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Computer-Assisted versus Conventional Free Fibula Flap Technique for Craniofacial Reconstruction: An Outcomes Comparison
Mitchel Seruya, MD1, Mark Fisher, BA2, Eduardo D. Rodriguez, MD, DDS3.
1Royal Children's Hospital, Melbourne, Australia, 2Johns Hopkins University School of Medicine, Baltimore, MD, USA, 3R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.

PURPOSE: There has been rising interest in computer-aided design and manufacturing (CAD/CAM) for the preoperative planning and execution of osseous free flap reconstruction. Virtual surgical planning and intraoperative cutting guides offer the potential of improving precision, accuracy, and efficiency. The purpose of this study was to compare outcomes between computer-assisted and conventional fibula free flap techniques for craniofacial reconstruction.
METHODS: A two-center, retrospective review was carried out of patients who underwent fibula free flaps for craniofacial reconstruction at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Hospital from 2004 to 2012. Patients were categorized by the type of reconstructive technique: CAD/CAM or conventional. Demographics, surgical factors, and outcomes were compared.
RESULTS: A total of 68 patients underwent microsurgical craniofacial reconstruction: 10 CAD/CAM and 58 conventional fibula free flaps. By demographics, CAD/CAM patients were significantly older, and with a higher rate of peripheral vascular disease and radiotherapy compared to conventional patients (Table I). Intraoperatively, the median number of osteotomies was significantly higher (2.0 versus 1.0, p=0.002) and median ischemia time was significantly shorter (120 versus 170 minutes, p=0.004) for CAD/CAM versus conventional techniques; operative times were shorter for CAD/CAM patients though this did not reach statistical significance (Table II). Perioperative and long-term outcomes were equivalent for the 2 groups, which included hospital length of stay, partial and total flap loss, and rate of soft and bony tissue revisions with re-osteotomies, grafts, or flaps.
CONCLUSIONS: Microsurgical craniofacial reconstruction using a computer-assisted fibula flap technique yielded significantly shorter ischemia times amidst a higher number of osteotomies compared to conventional techniques. With increased experience, these benefits may translate into improved clinical outcomes, reduced operative time and anesthetic morbidity.
TABLES
TABLE I. COMPARISON OF DEMOGRAPHICS
CAD/CAM Fibula Free Flap
N=10
Conventional Fibula Free
Flap
N=58
p value
Number%Number%
Age (years)59.043.00.02
Gender
Male550.0%3967.2%0.48
Female550.0%1932.8%
BMI22.525.10.26
Hypertension330.0%1322.4%0.69
Coronary artery disease220.0%23.4%0.10
Peripheral vascular disease220.0%00.0%0.02
Diabetes00.0%712.1%0.37
Chronic renal insufficiency00.0%23.4%1.00
Radiotherapy550.0%1017.2%0.04
Tobacco use110.0%2543.1%0.08

TABLE II. COMPARISON OF SURGICAL FACTORS AND INTRAOPERATIVE OUTCOMES
CAD/CAM Fibula Free Flap
N=10
Conventional Fibula Free
Flap
N=58
p value
Number%Number%
Indications
Mandible330.0%1831.0%1.00
Maxilla220.0%2543.1%0.29
Orbit330.0%712.1%0.16
Frontal220.0%813.8%0.63
Skin paddle surface area (cm2)32.040.00.80
Length of bone flap (cm)13.09.00.32
# Osteotomies2.01.00.002
Ischemia time (min)1201700.004
Operative time (min)6256480.21

TABLE III. COMPARISON OF PERIOPERATIVE AND LONG-TERM OUTCOMES
CAD/CAM Fibula Free Flap
N=10
Conventional Fibula Free
Flap
N=58
p value
Number%Number%
LOS (days)9.57.00.13
Length of follow-up (months)18.522.10.10
Partial skin loss (%)110.0%58.6%1.00
Partial bone loss (%)00.0%23.4%1.00
Total flap loss (%)110.0%23.4%0.38
Re-osteotomy (%)00.0%712.1%0.37
Skin graft (%)110.0%1017.2%0.69
Bone graft (%)110.0%1017.2%0.69
Local soft tissue flap (%)220.0%1424.1%1.00
2nd soft tissue free flap (%)00.0%1017.2%0.34
2nd bone free flap (%)00.0%11.7%1.00


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