Download PDF
J Reconstr Microsurg 2023; 39(03): 221-230
DOI: 10.1055/s-0042-1755260
Original Article

The Cost Utility of Virtual Surgical Planning and Computer-Assisted Design/Computer-Assisted Manufacturing in Mandible Reconstruction Using the Free Fibula Osteocutaneous Flap

David E. Kurlander 
1   Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
,
Patrick B. Garvey
1   Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
,
Rene D. Largo
1   Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
,
Peirong Yu
1   Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
,
Edward I. Chang
1   Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
,
Matthew M. Hanasono
1   Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
,
Alexander F. Mericli
1   Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Background The use of virtual surgical planning and computer-assisted design and computer-assisted manufacturing (CAD/CAM) has become widespread for mandible reconstruction with the free fibula flap. However, the cost utility of this technology remains unknown.

Methods The authors used a decision tree model to evaluate the cost utility, from the perspective of a hospital or insurer, of mandible reconstruction using CAD/CAM relative to the conventional (non-CAD/CAM) technique for the free fibula flap. Health state probabilities were obtained from a published meta-analysis. Costs were estimated using 2018 Centers for Medicare and Medicaid Services data. Overall expected cost and quality-adjusted life-years (QALYs) were assessed using a Monte Carlo simulation and sensitivity analyses. Cost effectiveness was defined as an incremental cost utility ratio (ICUR) less than the empirically accepted willingness-to-pay value of $50,000 per QALY.

Results Although CAD/CAM reconstruction had a higher expected cost compared with the conventional technique ($36,487 vs. $26,086), the expected QALYs were higher (17.25 vs. 16.93), resulting in an ICUR = $32,503/QALY; therefore, the use of CAD/CAM in free fibula flap mandible reconstruction was cost-effective relative to conventional technique. Monte Carlo sensitivity analysis confirmed CAD/CAM's superior cost utility, demonstrating that it was the preferred and more cost-effective option in the majority of simulations. Sensitivity analyses also illustrated that CAD/CAM remains cost effective at an amount less than $42,903 or flap loss rate less than 4.5%.

Conclusion This cost utility analysis suggests that mandible reconstruction with the free fibula osteocutaneous flap using CAD/CAM is more cost effective than the conventional technique.

Keywords

computer-assisted design and computer-assisted manufacturing - CAD/CAM - fibula flap - mandibulectomy - cost utility

Supplementary Material



Publication History

Received: 31 January 2022

Accepted: 29 May 2022

Article published online:
21 August 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Largo RD, Garvey PB. Updates in head and neck reconstruction. Plast Reconstr Surg 2018; 141 (02) 271e-285e
    CrossrefPubMedGoogle Scholar
  • 2 Roser SM, Ramachandra S, Blair H. et al. The accuracy of virtual surgical planning in free fibula mandibular reconstruction: comparison of planned and final results. J Oral Maxillofac Surg 2010; 68 (11) 2824-2832
    CrossrefPubMedGoogle Scholar
  • 3 Hirsch DL, Garfein ES, Christensen AM, Weimer KA, Saddeh PB, Levine JP. Use of computer-aided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction. J Oral Maxillofac Surg 2009; 67 (10) 2115-2122
    CrossrefPubMedGoogle Scholar
  • 4 Chang EI, Jenkins MP, Patel SA, Topham NS. Long-term operative outcomes of preoperative computed tomography-guided virtual surgical planning for osteocutaneous free flap mandible reconstruction. Plast Reconstr Surg 2016; 137 (02) 619-623
    CrossrefPubMedGoogle Scholar
  • 5 Wang YY, Zhang HQ, Fan S. et al. Mandibular reconstruction with the vascularized fibula flap: comparison of virtual planning surgery and conventional surgery. Int J Oral Maxillofac Surg 2016; 45 (11) 1400-1405
    CrossrefPubMedGoogle Scholar
  • 6 Zhang L, Liu Z, Li B, Yu H, Shen SG, Wang X. Evaluation of computer-assisted mandibular reconstruction with vascularized fibular flap compared to conventional surgery. Oral Surg Oral Med Oral Pathol Oral Radiol 2016; 121 (02) 139-148
    CrossrefPubMedGoogle Scholar
  • 7 Saad A, Winters R, Wise MW, Dupin CL, St Hilaire H. Virtual surgical planning in complex composite maxillofacial reconstruction. Plast Reconstr Surg 2013; 132 (03) 626-633
    CrossrefPubMedGoogle Scholar
  • 8 Weitz J, Bauer FJM, Hapfelmeier A, Rohleder NH, Wolff K-D, Kesting MR. Accuracy of mandibular reconstruction by three-dimensional guided vascularised fibular free flap after segmental mandibulectomy. Br J Oral Maxillofac Surg 2016; 54 (05) 506-510
    CrossrefPubMedGoogle Scholar
  • 9 Culié D, Dassonville O, Poissonnet G, Riss J-C, Fernandez J, Bozec A. Virtual planning and guided surgery in fibular free-flap mandibular reconstruction: a 29-case series. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 133 (03) 175-178
    CrossrefPubMedGoogle Scholar
  • 10 Toto JM, Chang EI, Agag R, Devarajan K, Patel SA, Topham NS. Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-guided preoperative planning. Head Neck 2015; 37 (11) 1660-1664
    CrossrefPubMedGoogle Scholar
  • 11 Garvey PB, Chang EI, Selber JC. et al. A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction. Plast Reconstr Surg 2012; 130 (04) 541e-549e
    CrossrefPubMedGoogle Scholar
  • 12 Chang EI, Boukovalas S, Liu J, Largo RD, Hanasono MM, Garvey PB. Reconstruction of posterior mandibulectomy defects in the modern era of virtual planning and three-dimensional modeling. Plast Reconstr Surg 2019; 144 (03) 453e-462e
    CrossrefPubMedGoogle Scholar
  • 13 Hanasono MM, Skoracki RJ. Computer-assisted design and rapid prototype modeling in microvascular mandible reconstruction. Laryngoscope 2013; 123 (03) 597-604
    CrossrefPubMedGoogle Scholar
  • 14 Wilde F, Hanken H, Probst F, Schramm A, Heiland M, Cornelius C-P. Multicenter study on the use of patient-specific CAD/CAM reconstruction plates for mandibular reconstruction. Int J CARS 2015; 10 (12) 2035-2051
    CrossrefPubMedGoogle Scholar
  • 15 Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC. Panel on Cost-Effectiveness in Health and Medicine. The role of cost-effectiveness analysis in health and medicine. JAMA 1996; 276 (14) 1172-1177
    CrossrefPubMedGoogle Scholar
  • 16 Siegel JE, Weinstein MC, Russell LB, Gold MR. Panel on Cost-Effectiveness in Health and Medicine. Recommendations for reporting cost-effectiveness analyses. JAMA 1996; 276 (16) 1339-1341
    CrossrefPubMedGoogle Scholar
  • 17 Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the panel on cost-effectiveness in health and medicine. JAMA 1996; 276 (15) 1253-1258
    CrossrefPubMedGoogle Scholar
  • 18 Padilla PL, Mericli AF, Largo RD, Garvey PB. CAD/CAM versus conventional surgical planning for head and neck reconstruction: a systematic review and meta-analysis. Plast Reconstr Surg 2021; 148 (01) 183-192
    CrossrefPubMedGoogle Scholar
  • 19 Thoma A, Haines T, Veltri K, Goldsmith CH, O'Brien BJ, Quartly C. A methodological guide to performing a cost-utility study comparing surgical techniques. Can J Plast Surg 2004; 12 (04) 179-187
    CrossrefPubMedGoogle Scholar
  • 20 Thoma A, Khuthaila D, Rockwell G, Veltri K. Cost-utility analysis comparing free and pedicled TRAM flap for breast reconstruction. Microsurgery 2003; 23 (04) 287-295
    CrossrefPubMedGoogle Scholar
  • 21 Chatterjee A, Krishnan NM, Van Vliet MM, Powell SG, Rosen JM, Ridgway EB. A comparison of free autologous breast reconstruction with and without the use of laser-assisted indocyanine green angiography: a cost-effectiveness analysis. Plast Reconstr Surg 2013; 131 (05) 693e-701e
    CrossrefPubMedGoogle Scholar
  • 22 Offodile II AC, Sheckter CC, Tucker A. et al. Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis. Breast Cancer Res Treat 2017; 165 (03) 477-484
    CrossrefPubMedGoogle Scholar
  • 23 Mericli AF, Rhines L, Bird J, Liu J, Selber JC. Immediate reconstruction of oncologic spinal wounds is cost-effective compared with conventional primary wound closure. Plast Reconstr Surg 2019; 144 (05) 1182-1195
    CrossrefPubMedGoogle Scholar
  • 24 Social Security Administration. 2017 Actuarial Life Table. Accessed July 8, 2022 at: https://www.ssa.gov/oact/STATS/table4c6.html
    PubMedGoogle Scholar
  • 25 Tarsitano A, Battaglia S, Crimi S, Ciocca L, Scotti R, Marchetti C. Is a computer-assisted design and computer-assisted manufacturing method for mandibular reconstruction economically viable?. J Craniomaxillofac Surg 2016; 44 (07) 795-799
    CrossrefPubMedGoogle Scholar
  • 26 Rommel N, Kesting MR, Rohleder NH, Bauer FMJ, Wolff K-D, Weitz J. Mandible reconstruction with free fibula flaps: outcome of a cost-effective individual planning concept compared with virtual surgical planning. J Craniomaxillofac Surg 2017; 45 (08) 1246-1250
    CrossrefPubMedGoogle Scholar
  • 27 Mazzola F, Smithers F, Cheng K. et al. Time and cost-analysis of virtual surgical planning for head and neck reconstruction: a matched pair analysis. Oral Oncol 2020; 100: 104491
    CrossrefPubMedGoogle Scholar
  • 28 Zweifel DF, Simon C, Hoarau R, Pasche P, Broome M. Are virtual planning and guided surgery for head and neck reconstruction economically viable?. J Oral Maxillofac Surg 2015; 73 (01) 170-175
    CrossrefPubMedGoogle Scholar
  • 29 Fatima A, Hackman TG, Wood JS. Cost-effectiveness analysis of virtual surgical planning in mandibular reconstruction. Plast Reconstr Surg 2019; 143 (04) 1185-1194
    CrossrefPubMedGoogle Scholar
  • 30 Legocki AT, Duffy-Peter A, Scott AR. Benefits and limitations of entry-level 3-dimensional printing of maxillofacial skeletal models. JAMA Otolaryngol Head Neck Surg 2017; 143 (04) 389-394
    CrossrefPubMedGoogle Scholar
  • 31 McAllister P, Watson M, Burke E. A cost-effective, in-house, positioning and cutting guide system for orthognathic surgery. J Maxillofac Oral Surg 2018; 17 (01) 112-114
    CrossrefPubMedGoogle Scholar
  • 32 Moe J, Foss J, Herster R. et al. An in-house computer-aided design and computer-aided manufacturing workflow for maxillofacial free flap reconstruction is associated with a low cost and high accuracy. J Oral Maxillofac Surg 2021; 79 (01) 227-236
    CrossrefPubMedGoogle Scholar
  • 33 Li SS, Copeland-Halperin LR, Kaminsky AJ, Li J, Lodhi FK, Miraliakbari R. Computer-aided surgical simulation in head and neck reconstruction: a cost comparison among traditional, in-house, and commercial options. J Reconstr Microsurg 2018; 34 (05) 341-347
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Haddock NT, Monaco C, Weimer KA, Hirsch DL, Levine JP, Saadeh PB. Increasing bony contact and overlap with computer-designed offset cuts in free fibula mandible reconstruction. J Craniofac Surg 2012; 23 (06) 1592-1595
    CrossrefPubMedGoogle Scholar
  • 35 Ch'ng S, Skoracki RJ, Selber JC. et al. Osseointegrated implant-based dental rehabilitation in head and neck reconstruction patients. Head Neck 2016; 38 (Suppl. 01) E321-E327
    CrossrefPubMedGoogle Scholar
  • 36 Monaco C, Stranix JT, Avraham T. et al. Evolution of surgical techniques for mandibular reconstruction using free fibula flaps: the next generation. Head Neck 2016; 38 (Suppl. 01) E2066-E2073
    CrossrefPubMedGoogle Scholar
  • 37 Nelson JA, Allen Jr RJ, Rosen EB, Matros E. Cost-effectiveness and virtual surgical planning in head and neck reconstruction: measuring what matters most. Plast Reconstr Surg 2021; 147 (06) 1091e-1092e
    CrossrefPubMedGoogle Scholar
  • 38 Lee Z-H, Avraham T, Monaco C, Patel AA, Hirsch DL, Levine JP. Optimizing functional outcomes in mandibular condyle reconstruction with the free fibula flap using computer-aided design and manufacturing technology. J Oral Maxillofac Surg 2018; 76 (05) 1098-1106
    CrossrefPubMedGoogle Scholar