Application of high-tech three-dimensional imaging and computer-generated models in complex facial reconstructions...

We present a series of six patients with eight flaps in whom computer-generated models were used for fabrication of vascularized bone grafts in complex facial restorations. Preoperative CT data, digitalized on tape, were converted by the CEMAX (Santa Clara, Calif.) 1500 Integrated Hardware and Software System to a three-dimensional visualization of the bone and soft-tissue deficiencies. These data were transmitted by direct computer link to a CNC milling machine that produced full-size slices "stacked" into a three-dimensional template. The acrylic replica aided selection of appropriate donor sites and intraoperative "carving" of bone transfers. Reconstructions included three zygomas, two maxillae, two mandibles, and one frontal bone. Donor sites were iliac crest, scapula, and outer calvarium. Four were free flaps and four island pedicle flaps. All healed without infection. Bone resorption was less than 10 percent. One flap was lost to thrombosis. Other complications included a transient facial palsy in one patient and temporary radial palsy from shoulder traction in another. Computer-generated templates for vascularized grafts are expensive and thus are not indicated or necessary in every patient. The advantages, however, are several. Custom models facilitate preoperative planning, with less guesswork of size, contour, and orientation of the graft, which is especially desirable with vascularized grafts, since the position of the pedicle is critical. Anesthesia time is decreased. Grafts can be fitted exactly, without reshaping and "nibbling." Nuances of depth and tapering are directly carved into the bone. By merging high-tech imaging and microsurgery, the best chance of optimal results can be achieved.