Virtual Surgical Planning: The Pearls and Pitfalls

Johnny I. Efanov, MD; Andrée-Anne Roy, MD; Ke N. Huang, MD; Daniel E. Borsuk, MD, MBA


Plast Reconstr Surg Glob Open. 2018;6(1):e1443 

In This Article

Abstract and Introduction


Objective: Over the past few years, virtual surgical planning (VSP) has evolved into a useful tool for the craniofacial surgeon. Virtual planning and computer-aided design and manufacturing (CAD/CAM) may assist in orthognathic, cranio-orbital, traumatic, and microsurgery of the craniofacial skeleton. Despite its increasing popularity, little emphasis has been placed on the learning curve.

Methods: A retrospective analysis of consecutive virtual surgeries was done from July 2012 to October 2016 at the University of Montreal Teaching Hospitals. Orthognathic surgeries and free vascularized bone flap surgeries were included in the analysis.

Results: Fifty-four virtual surgeries were done in the time period analyzed. Forty-six orthognathic surgeries and 8 free bone transfers were done. An analysis of errors was done. Eighty-five percentage of the orthognathic virtual plans were adhered to completely, 4% of the plans were abandoned, and 11% were partially adhered to. Seventy-five percentage of the virtual surgeries for free tissue transfers were adhered to, whereas 25% were partially adhered to. The reasons for abandoning the plans were (1) poor communication between surgeon and engineer, (2) poor appreciation for condyle placement on preoperative scans, (3) soft-tissue impedance to bony movement, (4) rapid tumor progression, (5) poor preoperative assessment of anatomy.

Conclusion: Virtual surgical planning is a useful tool for craniofacial surgery but has inherent issues that the surgeon must be aware of. With time and experience, these surgical plans can be used as powerful adjuvants to good clinical judgement.


Over the past 15 years, the advent of virtual surgical planning (VSP) and computer-aided design and manufacturing, CAD/CAM, of 3D stereolithographic models and osteotomy guides have contributed to a significant evolution of craniomaxillofacial surgery. The usefulness of the technique has been widely published in the plastic surgery and maxillofacial surgical literature.[1–6]

The VSP has been used for numerous types of orthognathic procedures including Le Fort I, II, III osteotomies, bilateral sagittal split osteotomies, distraction procedures of the upper and mid face, and genioplasties. Moreover, several reports have elucidated the benefits of the technique in cranioorbital procedures, perhaps the biggest change in the field since Tessier and Del Monasterio's initial drawings of the techniques. The VSP has been used in traumatic cases, where its use has been limited, and in free osteocutaneous procedures of the craniofacial skeleton, where its use has been widely adopted by oncologic reconstruction surgeons.

Despite all the potential uses for the virtual plans, its potential benefits of reducing operative times and the possibility of a more precise control of the final outcome, there exists a paucity of information regarding the inherent difficulties associated with the technique. This study aims to discuss the potential pitfalls encountered during the learning curve when VSP is incorporated in a craniofacial practice and to propose algorithms to help avoid these pitfalls.