The utility of three-dimensional models in complex microsurgical reconstruction

Abstract

Background: Three-dimensional (3D) model printing improves visualization of anatomical structures in space compared to two-dimensional (2D) data and creates an exact model of the surgical site that can be used for reference during surgery. There is limited evidence on the effects of using 3D models in microsurgical reconstruction on improving clinical outcomes.

Methods: A retrospective review of patients undergoing reconstructive breast microsurgery procedures from 2017 to 2019 who received computed tomography angiography (CTA) scans only or with 3D models for preoperative surgical planning were performed. Preoperative decision-making to undergo a deep inferior epigastric perforator (DIEP) versus muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap, as well as whether the decision changed during flap harvest and postoperative complications were tracked based on the preoperative imaging used. In addition, we describe three example cases showing direct application of 3D mold as an accurate model to guide intraoperative dissection in complex microsurgical reconstruction.

Results: Fifty-eight abdominal-based breast free-flaps performed using conventional CTA were compared with a matched cohort of 58 breast free-flaps performed with 3D model print. There was no flap loss in either group. There was a significant reduction in flap harvest time with use of 3D model (CTA vs. 3D, 117.7±14.2 minutes vs. 109.8±11.6 minutes; P=0.001). In addition, there was no change in preoperative decision on type of flap harvested in all cases in 3D print group (0%), compared with 24.1% change in conventional CTA group.

Conclusions: Use of 3D print model improves accuracy of preoperative planning and reduces flap harvest time with similar postoperative complications in complex microsurgical reconstruction.

Keywords: Breast; Lymphedema; Microsurgery.

Fig. 1.. 3D model of abdominal perforators

(A) Anterior view and (B) lateral view. 3D, three dimensional.

Fig. 2.. 3D model in complex burn reconstruction

Three-dimensional (3D) modeling using computed tomography angiography (CTA) identifies the availability of a thoracodorsal artery perforator flap in a burn patient with limited donor sites (A). Arrows indicate a thoracodorsal artery perforator on preoperative 3D CTA (A). Preoperative imaging guides intraoperative dissection of a thoracodorsal artery perforator flap harvest (B) for neck burn scar contracture.

Fig. 3.. 3D model for vascularized lymph node transfer

Preoperative computed tomography angiography (CTA) (A) and three-dimensional (3D) printed model (B) demonstrate the availability of the medial circumflex femoral recipient vessels for vascularized lymph node transfer (C). The preoperative images and model accurately predict the anatomy seen intraoperatively. The white arrows indicate the medial circumflex femoral artery. Preoperative CTA (D) and 3D printed model (E) demonstrate a patent lateral sural artery recipient site for vascularized lymph node transfer. The preoperative models accurately guide the intraoperative dissection (F). The white and black arrows demonstrate the lateral sural artery. 3D printed model (H) based on preoperative CTA (G) accurately predicts the availability of anterior tibial artery recipient site for vascularized lymph node transfer. The models accurately reflect the vascular anatomy encountered intraoperatively (I). The white and black arrows indicated the anterior tibial artery.

Fig. 4.. 3D printed model for breast reconstruction

Three-dimensional (3D) printed model (center) accurately predicts the vascular anatomy seen intraoperatively in a patient that was planned for a 3-perforator deep inferior epigastric perforator (DIEP) on the right and 2-perforator DIEP on the left, and the dissection is centered around these perforators (yellow arrows). The surgeon went straight for them and felt very comfortable sacrificing everything else based on 3D model.