Computerized Surgical Planning in Face Transplantation

Abstract

Face transplantation (FT) has emerged as a critical intervention for patients with complex facial deformities unsuitable for conventional reconstructive methods. It aims to restore essential functions such as facial expression, mastication, and speech, while also improving psychosocial health. The procedure utilizes various surgical principles, addressing unique challenges of craniofacial complexity and diverse injury patterns. The integration of Computerized Surgical Planning (CSP) leverages computer-aided technologies to enhance preoperative strategy, intraoperative navigation, and postoperative assessment. CSP utilizes three-dimensional computed tomography, printing, angiography, and navigation systems, enabling surgeons to anticipate challenges and reduce intraoperative trial and error. Through four clinical cases, including a groundbreaking combined face and bilateral hand transplant, CSP's role in FT is highlighted by its ability to streamline operative processes and minimize surgical revisions. The adoption of CSP has led to fewer cadaveric rehearsals, heightened operative precision, and greater alignment with preoperative plans. Despite CSP's advancements, it remains complementary to, rather than a replacement for, clinical expertise. The demand for technological resources and multidisciplinary teamwork is high, but the improved surgical outcomes and patient quality of life affirm CSP's value in FT. The technology has become a staple in reconstructive surgery, signaling a step forward in the evolution of complex surgical interventions.

Keywords: CSP; Computerized Surgical Planning; VCA; face transplant; facial reconstruction; facial trauma; transplant; vascularized composite allografts.

Fig. 1

Pre- and postoperative images of patient 1. ( A ) Preoperative frontal view. ( B ) Preoperative lateral view. ( C ) Postoperative frontal view. (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 2

Superimposition of the preoperative computed tomography (CT) of patient 1 and that of the donor, representing the computerized surgical plan with the goal of achieving normal cephalometric indices of a sella–nasion-A point of 81.73 degrees, a sella–nasion-B point of 82.21 degrees, and an occlusal angle of 2.4 degrees relative to the Frankfort horizontal plane of the recipient. (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 3

Postoperative computed tomography (CT) of patient 1 posttransplant with cephalometric analysis demonstrating minimal variation from the preoperative computerized surgical plan with a sella–nasion-A point of 80.64 degrees, a sella–nasion-B point of 80.21 degrees, and an occlusal angle of 3.85 degrees. (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 4

and postoperative images of patient 2. ( A ) Preoperative frontal view. ( B ) Preoperative lateral view. ( C ) Postoperative frontal view. (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 5

Computerized Surgical Planning for patient 2. ( A ) Donor computed tomography (CT) with planned osteotomies of skeletal subunits ( yellow ) and customized cutting guides ( pink ). ( B ) Recipient CT with planned osteotomies of skeletal subunits to be removed ( green ) and customized cutting guides ( pink ). (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 6

Pre- and postoperative images of patient 3. ( A ) Preoperative frontal view. ( B ) Preoperative lateral view. ( C ) Postoperative frontal view. (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 7

Computerized surgical plan of donor and recipient osteotomies for patient 3. ( A ) Donor-specific customized cutting guides ( silver ) for osteotomies of skeletal segments ( blue ). ( B ) Recipient-specific customized cutting guides ( silver ) for removal of recipient skeletal segments ( red ). ( C ) Superimposition of donor skeletal segments ( blue ) onto planned recipient skeletal defect. ( D ) Postoperative computed tomography (CT) of patient 3 with donor skeletal segments represented in orange . (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 8

Real-time intraoperative surgical navigation used in patient 3 to confirm accurate allograft skeletal inset. The green shaded area represents the computerized surgical plan and was compared with actual positioning of skeletal segments. Registration device in top images facilitated real-time surgical navigation, and accuracy was verified with intraoperative computed tomography (CT; bottom right image). (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 9

Pre- and postoperative images of patient 4. ( A ) Preoperative frontal view. ( B ) Preoperative lateral view. ( C ) Postoperative frontal view. (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 10

Pre- and postoperative images of bilateral upper extremities of patient 4. ( A ) Volar view of the preoperative left upper extremity. ( B ) Volar view of the preoperative right upper extremity. ( C ) Volar view of the postoperative left upper extremity. ( D ) Volar view of the postoperative right upper extremity. (Reproduced with permission of and copyrights retained by E.D.R.).

Fig. 11

Computerized surgical plan (CSP) compared with postoperative outcomes. ( A ) Frontal facial view of CSP compared with actual results. ( B ) Lateral facial view of CSP compared with actual results. ( C ) CSP of the bilateral upper extremities compared with actual results. (Reproduced with permission of and copyrights retained by E.D.R.)

Fig. 12

( A ) High-fidelity 3D-printed face mask and ( B ) bilateral upper extremities prostheses to maintain donor integrity after allograft procurement. (Reproduced with permission of and copyrights retained by E.D.R.)