Virtual Planning and Computer-Guided Surgery for Resection and Reconstruction of Craniomaxillofacial and Skull Base Tumors

Introduction: Craniomaxillofacial and skull base tumors can be very aggressive and adjacent to critical anatomic structures. Careful assessment of the tumor extension is critical for successful tumor resection. In the last few decades, difficulty to perform these aggressive resections not only because of the nature of the required resection but also due to the inability to easily reconstruct the resulted defect with function and esthetic restoration to improve prognosis as well as the quality of life . Virtual planning and 3D models help the clinicians to better virtualize the anatomy of surgical site, tumor extension and adjacent vital structures preoperatively using digital radiographic softwares.

Materials and Methods: A retrospective study is performed on patients of craniomaxillofacial and skull base tumors of different sites such as temporal, infratemporal, orbital, maxillary and mandibular sites with or without intracranial extension between 2017 and 2023. The virtual planning and computer-guided resection and reconstruction were utilized in all patients with or without microvascular free flaps (n = 174). A preoperative contrast-enhanced CT and MRI on head and neck region are required for assessment of the tumor. CT is used for virtual planning and designing of the resection osteotomy guides. CT angiography of lower limb (in cases of reconstruction by fibula free flap), iliac bone (reconstruction by DCIA free flap), shoulder (reconstruction by scapula free flap) were required for reconstruction virtual planning and designing the cutting guides and patient-specific plates and implants.

Results: A total of 174 patients of craniomaxillofacial and skull base tumors, 55 maxillary lesions, 74 mandibular lesions, 23 lesions extended to orbits and zygoma, 11 extended to Sino-nasal region, 6 frontal lesions, 19 temporal and infra temporal lesions, 98 associated neck metastasis and 7 lesions with intracranial extension. Lesions were histopathologically-proven showing a variety of pathological conditions. There were 118 females (67.8%) and 56 males (32.2%). Reconstruction was performed using computer-guided surgical protocol with various free flaps. A total resection of the tumors was carried out in all patients with free safety margins from 1 to 3 cm according to the tumor’s guidelines. The histopathologically proven free margins and the preoperative virtual planned safety margins were identical in 166 cases (95.4%) of the cases. Follow-up revealed tumor recurrence in four cases, two mesenchymal types of chondrosarcoma after 1.5 and 1 years, a case of high-grade mucoepidermoid carcinoma after 22 months, and a case of poorly differentiated squamous cell carcinoma after 2 years. With mortality of 3 cases (0.017%) and just one case free flap failure, DCIA free flap.

Conclusion: Preoperative surgical planning, 3D modeling and computer-guided design of osteotomy guides, and custom-made plates and implants offer a lot of benefits for the patients of craniomaxillofacial and skull base tumors to improve quality of tumor resection and ablation, guided reconstruction for these defect-producing surgeries, dramatically reducing the operation time and efforts and magnificently improvement of the functional and esthetic outcomes. These ultra-major surgeries with intracranial extension should be performed with the aid of multidisciplinary teamwork, craniomaxillofacial team and skull base neurosurgery team.

 

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Artikel online veröffentlicht:
07. Februar 2025