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


We conducted a retrospective review of virtual surgical plans done in our institutions between July 2012 and October 2016. Patients were treated in academic centers of University of Montreal, Hôpital Sainte-Justine for children and Hôpital Maisonneuve-Rosemont for adults. All virtual plans were performed by 1 surgeon (senior author) and 1 senior computer engineer. An analysis of the utility of the virtual plans was done pre-, peri-, and postoperatively and documented in the patient's chart.

We obtained approval from our institution's ethics review board to perform a retrospective chart review on all the patients. Inclusion criteria included patients of all ages operated for a craniofacial reconstruction or orthognathic surgery with the use of VSP. Target endpoints recorded from each chart included complete adherence to VSP, complete adherence with minor difficulties, incomplete adherence, or complete abandonment of virtual surgical plan.


A step-by-step algorithmic approach is depicted in Figure 1. To perform VSP, one must acquire precise imaging of the craniofacial skeleton with a minimum of 1 mm cuts on a computed tomography (CT) scan. For cases where osteocutaneous fibular free flaps were necessary, we performed computed tomographic angiography as well to evaluate the vascularization and presence of a peroneus magnus when available. The CT scan data were then uploaded and shipped to the engineers (Materialise, Leuven, Belgium) using the Digital Imaging and Communications in Medicine format, and dental occlusal casts in final occlusion were included for the orthognathic cases. Online meetings were performed with the surgeon and engineers to incorporate clinical findings with skeletal movements in all cases. The virtual plan was accepted by the surgeon before 3-dimensional printing of the occlusal splints and cutting guides. The surgical oncologist was included in all online meetings before printing guides for the free tissue transfer cases.

Figure 1.

Algorithmic approach to virtual surgical planning. A, Step-by-step approach for the planning of orthognathic cases. B, Approach to free osseous flaps performed with virtual surgery planning.