IDEAS AND INNOVATIONS

Use of Virtual Surgery and Stereolithography-

Guided Osteotomy for Mandibular
Reconstruction with the Free Fibula
Anuja K. Antony, M.D.,
M.P.H.
Wei F. Chen, M.D.
Antonia Kolokythas, D.D.S.
Katherine A. Weimer, M.S.
Mimis N. Cohen, M.D.
Chicago, Ill.; and Golden, Colo.
Summary: Fibular osteotomy remains a challenging aspect of mandibular micro-
surgical reconstruction, dependent largely on surgeon experience, intraoperative
judgment, and technical speed. Virtual surgical planning and stereolithographic
modeling is a relatively new technique that can allow for reduction in the learning
curve associated with neomandible contouring, enhanced levels of accuracy, and
acceleration of a time-consuming intraoperative step. The authors present a video
(narrated and edited from planning sessions and intraoperative use of technique
to illustrate the technology) and describe their favorable results. Five patients
underwent composite resection of the mandible and free fibula osteocutaneous
reconstruction over a 6-month period (December of 2009 to June of 2010) at a
single institution using a virtual planning session and stereolithographic modeling.
Outcomes assessed included technical accuracy, aesthetic contour, and functional
outcomes. All patients achieved negative margins with cutting guide– directed re-
section. Use of this technique eliminated the need for intraoperative measurement
and yielded fibular segments with excellent apposition and faithful duplication of
the preoperative plan. Minimal adjustments were needed for inset. Flap survival was
100 percent. All patients have maintained preoperative occlusion and a symmetric
mandibular contour on Panorex study, three-dimensional computed tomography,
and clinical examination. Accuracy of the reconstructed contour was confirmed
using computed tomographic image overlay. This virtual surgical planning tech-
nique combined with stereolithographic model– guided osteotomy is the mainstay
of the authors’ approach to fibular osteotomy when dealing with patients requiring
mandibular reconstruction. The authors feel this technology facilitates realization of
technical accuracy, aesthetic contour, and functional outcomes and may be particularly
useful if free fibular mandibular reconstruction is performed less frequently. (Plast.
Reconstr. Surg. 128: 1080, 2011.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

M
icrovascular free fibular transfer has be-
come the procedure of choice in mandi-
ble reconstruction because of its favor-
able osseous characteristics.1 Although modern
innovations have vastly improved the accuracy of
the reconstruction,2,3 fibular osteotomy and neo-
From the Division of Plastic and Reconstructive Surgery and
the Department of Oral and Maxillofacial Surgery, Univer-
sity of Illinois at Chicago, and Virtual Surgical Planning
Services, Medical Modeling, Inc.
Received for publication July 13, 2010; accepted March 23, 2011.
Presented at the 49th Annual Scientific Meeting of the Mid-
western Association of Plastic Surgeons, in Chicago, Illinois,
May 15 through 16, 2010; and the 2011 Annual Meeting
of the American Society of Reconstructive Microsurgery, in
Cancun, Mexico, January 15 through 18, 2011.
Copyright ©2011 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e31822b6723
mandible contouring remains a challenging aspect
of the reconstruction and is dependent largely on
surgeon experience, intraoperative judgment, and
technical speed.
New technology has emerged that allows vir-
tual surgical planning and accurate intraoperative
execution with the aid of stereolithographic mod-
eling and a reduction in the learning curve asso-
ciated with mandibular reconstruction. This
method holds potential for enhanced levels of
precision and acceleration of a time-consuming
Disclosure: Katherine A. Weimer is a manager for
Virtual Surgical Planning Services of Medical Mod-
eling, Inc. None of the remaining authors has any
financial or commercial associations to disclose.

1080 www.PRSJournal.com
Volume 128, Number 5 • Mandibular Microsurgical Reconstruction

intraoperative step.4,5 We describe our early, fa-

vorable experience with this technical approach
and illustrate the technique with an instructive
video of the planning session, intraoperative os-
teotomies, and postoperative results. We feel this
type of planning has merit not only in larger can-
cer centers but also in institutions that treat head
and neck cancer with lower volumes of free fibula
reconstruction.

SURGICAL TECHNIQUES
Virtual Surgical Planning
High-resolution computed tomographic scans
(1-mm fine cuts) of the maxillofacial skeleton and
lower extremities are obtained and forwarded to
Medical Modeling, Inc. (Golden, Colo.) for three- Video. Supplemental Digital Content 1, which demonstrates
dimensional rendering using Materialise software virtual surgical planning (narrated and edited from planning
(Leuven, Belgium). [See Video, Supplemental sessions), intraoperative use of stereolithography-guided os-
Digital Content 1, which demonstrates virtual sur- teotomy technique, and before and after results, is available at
gical planning (narrated and edited from plan- http://links.lww.com/PRS/A392.
ning sessions), intraoperative use of stereolithog-
raphy-guided osteotomy technique, and before
and after results, http://links.lww.com/PRS/A392.]
A Web-based teleconference is held between a
biomedical engineer at Medical Modeling, Inc.,
and the extirpative and reconstructive surgical
teams. Coordinating efforts for the planning is
relatively simple, as each user is granted remote
access to the planning session by means of con-
ference call and computer link-up; a typical plan-
ning session lasts approximately 30 minutes or
less. Directed by the ablative surgeon, virtual re-
section is performed to facilitate appropriate mar-
gins. The reconstructive surgeon then directs
virtual reconstruction by superimposing the pa-
tient’s own three-dimensional reconstructed (or a
generic) fibula onto the mandibular defect and Fig. 1. After virtual resection, virtual reconstruction is con-
placing fibular osteotomies to recreate the native ducted by superimposing the three-dimensional patient-spe-
mandibular contour through a trial-and-error pro- cific or generic fibula onto the mandibular defect. Fibular osteot-
cess, optimizing the number and cutting plane of omies are placed to recreate the native mandibular contour
the osteotomies, bone-to-bone contact, and fibular through a trial-and-error process, optimizing the number and
segment lengths (Fig. 1). With these data, stereo- cutting plane of the osteotomies, bone-to-bone contact, and fib-
lithographic models of the neomandible, mandib- ular segment lengths.
ular and fibular cutting guides, and a plate-bend-
ing template are manufactured. A reconstruction
plate is prebent preoperatively using the manu-
Supplemental digital content is available for factured neomandible model and plate-bending
this article. A direct URL citation appears in template as a guide.
the printed text; simply type the URL address
into any Web browser to access this content. A
clickable link to the material is provided in the Surgical Technique
HTML text of this article on the Journal’s Web The surgery proceeds with a two-team ap-
site (www.PRSJournal.com). proach. After adequate exposure has been ob-
tained, the prebent reconstruction plate is pre-

1081
 Plastic and Reconstructive Surgery • November 2011
screwed to the native mandible with the patient in
maxillomandibular fixation. The plate is then re-
moved and sterilized for later use in the leg. The
mandibular cutting guide is then secured to the
mandible and the osteotomies are performed with
a reciprocating saw guided by the cutting slots,
effectively replicating the virtually planned man-
dibular osteotomies. The fibula is concurrently
dissected with a lateral approach and isolated on
its vascular pedicle. The fibular cutting guide is
secured to the fibula with lateral unicortical screws
(guide placement can be adjusted according to
perforator location if a skin island is required).
Orienting the vascular pedicle and lengthening
the pedicle by subperiosteal dissection of the fib-
ula is an important aspect of planning to avoid the
use of vein grafts in the neck. With the pedicle
protected by a small malleable retractor, cutting
guide– directed osteotomies are performed with
an oscillating sagittal saw (typically, 10 to 15 min-
utes). The fibular segments are then fixed to the
reconstruction plate in situ, the neomandible
shape is confirmed (Fig. 2), and the vascular pedi-
cle is divided. The neomandible/reconstruction
plate is transferred as a unit and secured to the
mandibular remnant at its predetermined optimal
position. The microvascular anastomoses, soft-tis-
sue inset, and wound closure are completed in
standard fashion.
PATIENTS AND METHODS
This ongoing prospective study has accrued
five patients who underwent composite resection
Fig. 2. The fibular segments assembled into the neomandible.
Excellent bone-to-bone approximation is achieved with minimal
adjustments needed. Cutting guide– directed osteotomies in-
corporate the planned contour of neomandible, ensuring a pre-
cise reconstruction.
1082
of the mandible and free fibula osteocutaneous
reconstruction, between December of 2009 to
June of 2010, by one surgeon (A.K.A.) at a single
institution. Age ranged from 18 to 63 years, with
two women and three men. Follow-up ranged
from 9.5 to 14.4 months (Table 1). All patients
underwent virtual planning and reconstruction as
described. Outcomes assessed included technical
accuracy (computed tomographic image overlay),
aesthetic contour, and functional outcomes. The
functional and aesthetic outcomes were assessed
by dental occlusion, postoperative imaging [Pan-
orex (S. S. White Technologies, Inc., Piscataway,
N.J.) and computed tomography], and clinical ex-
amination.
RESULTS
All patients achieved negative margins with
cutting guide– directed resection. Using cutting
guides for mandibular and fibular osteotomies
eliminated the need for intraoperative measure-
ment and/or real-time navigational technology6
and at the same time provided surgeons with con-
fidence in a faithful duplication of preoperative
virtual surgical planning. The resulting fibular seg-
ments yielded excellent apposition. Minimal ad-
justments were needed in insetting.
Flap survival was 100 percent. There were no
wound complications. All patients achieved pre-
operative occlusion and a symmetric mandibular
contour on Panorex study, three-dimensional
computed tomography, and clinical examination.
The accuracy of the reconstructed contour was
confirmed using image superimposition with the
native mandible and virtual plan (Fig. 3).
DISCUSSION
Since its introduction by Hidalgo in 1989,7
contouring of a free fibular flap has been classi-
cally performed with a freehand approach. Favor-
able results are obtained through accumulation of
experience and “sculpture skill.”8 The process is
Table 1. Patient Demographics
Age Follow-Up
Patient (yr) Sex Abnormality Resection (mo)
1 24 M Ameloblastoma Body, ramus 14.4
2 19 F SCC Symphysis, 12.4
body
3 63 M SCC Symphysis, 10.5
body
4 61 M SCC Symphysis, 10
body
5 59 F SCC Symphysis, 9.5
body
M, male; F, female; SCC, squamous cell carcinoma.
Volume 128, Number 5 • Mandibular Microsurgical Reconstruction

Fig. 3. Postoperative three-dimensional computed tomographic

scans demonstrated faithful replication of virtual surgical planning
(above). Volumetric analysis with image superimposition showed ex-
cellent alignment of native mandible, the virtual reconstruction, and
the neomandible.

Fig. 4. Flow chart shows intraoperative time savings using stereolithographic models
and virtual surgery. Elimination of intraoperative plate bending, accelerated cutting
guide– directed fibular osteotomy, and the accelerated fibular flap inset/fixation
translate into considerable saving of intraoperative time compared with the tradi-
tional technique.

less accurate and subject to human error. Indeed,
the fibular osteotomy is considered by many re-
constructive surgeons the most challenging and
time-consuming step,2–5 with an average operative
time of 60 minutes.
With the advent of computer-aided surgical
planning in a virtual environment, repeated sim-
ulation in the virtual world allows for an optimal
set of osteotomies. The computer-planned man-
dibular osteotomies, performed correctly, can
produce adequate margins without the need for
intraoperative changes in the surgical plan. With
the described approach, the plate bending is
turned into a preoperative event, saving valuable

1083
 Plastic and Reconstructive Surgery • November 2011
intraoperative time. In virtual planning, the recon-
struction plate can be contoured in close apposition
to the mandible even in the presence of a contour-
deforming malignancy, which would normally hin-
der an accurate intraoperative contouring.
Fibular osteotomy is greatly accelerated because
the need for intraoperative freehand contouring is
eliminated. The fibular segments are assembled into
the neomandible with excellent bone-to-bone ap-
proximation, with minimal adjustments needed for
final inset. All of the above translate into a consid-
erable saving of intraoperative time (Fig. 4) and
accelerate the learning curve process, marrying vir-
tual experience (effort investment) with efficiency
gains in the operating room.
The enhanced communication between the
ablative and reconstructive surgeons is one of the
most important benefits we experienced with this
approach. Through the preoperative Web-based
conference with the ablative surgical team, we co-
ordinate the anticipated location and size of de-
fect with the reconstructive bony requirements.
The synergy between the two surgical teams allows
for a synchronized strategic surgical plan with im-
proved intraoperative efficiency and excellent pa-
tient outcomes.
CONCLUSIONS
Our preliminary experience with the approach
of fibular contouring with stereolithography-
guided osteotomies in mandibular reconstruction
is highly favorable. We feel it is an excellent al-
ternative to conventional freehand osteotomy and
that its added effort investment is more than offset
by its potential for accelerated intraoperative ef-
ficiency, improved patient outcomes, and value in
resident training. Future efforts should be di-
rected toward formal quantification of benefits,
1084
including marginal utility, medical error reduc-
tion, and cost-to-benefit analysis. We describe our
early, favorable experience with this technical ap-
proach and illustrate the technique with an in-
structive video.
Anuja K. Antony, M.D., M.P.H.
Division of Plastic, Reconstructive, and
Cosmetic Surgery
MC 958
University of Illinois at Chicago
820 South Wood Street
Chicago, Ill. 60612
akantony@uic.edu
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