Simplifying Bony Midface Reconstruction with Patient-specific Titanium Plates

Abstract

Virtual surgical planning and patient-specific osteosynthesis plates provide reconstructive surgeons with the ability to proceed with facial reconstruction of expanding complexity. Moreover, these advances have been shown to reduce the energy, effort, and operating time while helping guide the surgeon toward anatomically correct results. The currently available literature regarding custom-milled plates pertains mostly to reconstructive surgery of the mandible. This small 3-patient series illustrates the use of patient-specific titanium plating to simplify complex reconstruction of the midface. Composite defects requiring multiple bony and soft tissue segments are difficult to reconstruct intraoperatively without prior planning. Custom plates and associated cutting guides based on patient-specific anatomy allow for a more streamlined, stepwise protocol for assembly of intricate constructs. Custom-manufactured hardware will precisely fit bony contours and minimize additional manipulation of both the bone and plate, maximally preserving internal strength and allowing for improved stability, dental occlusion, and spatial positioning. In addition to these mechanical benefits, the ease of mind and overall cost reduction through a reduction in procedural time are significant advantages offered by pre-designed plates. We hope that this series illustrates the value of custom-printed plates for midface reconstruction.

Fig. 1.

A 61-year-old man with complex composite midface defect secondary to remote ablative procedure and radiation. A, VSP was used to design a 3-segment fibula flap and patient-specific laser-sintered titanium plate with 18 predesigned screw holes optimally placed to fixate the construct to the right hemimaxilla and left zygoma. B, Postoperative 3-dimensional computerized tomography model showing the installed construct and final hardware.

Fig. 2.

A 50-year-old woman with composite tissue defects of both the maxilla and mandible secondary to self-inflicted gunshot wound. Image from VSP that demonstrates the planned fibula constructs for simultaneous maxillary and mandibular reconstruction, and patient-specific design of laser-sintered titanium midface plate and prefabricated custom osteotomy guide. Notably, predictive marking holes indicate the relationship between the final and original fibula segments, facilitating easy assembly of the constructs.

Fig. 3.

A 25-year-old man with partial maxillary defect secondary to prior resection of Ewing’s sarcoma. Postoperative 3-dimensional CT image demonstrates the inset fibula construct and patient-specific laser-sintered titanium plates. The patient also underwent immediate placement of osseointegrated implant posts for future dental restoration. Here, the ability of individualized custom plates to precisely fit areas of contour is well demonstrated.