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


In total, there were 54 patients who required VSP for craniofacial cases. Indications for virtual surgical plan included 85% (n = 46) for orthognathic correction of dento-skeletal malocclusion and 15% (n = 8) for free vascularized bone flaps for reconstruction of the facial skeleton. Within the orthognathic group, 39% (n = 18) were for patients with cleft lip and palate deformities, 26% (n = 12) were patients with hemifacial macrosomia, 4% (n = 2) had syndromic craniosynostosis, and 4% (n = 2) had cleido-cranial dysostosis. Twenty-two percentage of patients (n = 10) had other congenital dento-skeletal deformities, whereas the remaining 4% (n = 2) had acquired deformities. Eighty-five percentage of patients (n = 39) had double jaw surgery, whereas the remaining only had 1 jaw surgery.

Within the patients requiring free tissue transfers to the facial skeleton, 75% (n = 6) had mandibular reconstruction with free osteocutaneous fibula flaps, 12.5% (n = 1) had a mandibular reconstruction with a free osteocutaneous radial forearm flap, and 12.5% (n = 1) had zygomatic-maxillary reconstruction for chronic osteomyelitis with a deep circumflex iliac artery iliac crest osseous flap.

Adherence to the initial virtual surgical plan is illustrated in Figure 2. Eighty-five percentage (n = 46) of all plans were adhered to completely, with 9% (n = 4) orthognathic and 25% (n = 2) free tissue transfers being partially adhered to and 4% (n = 2) orthognathic virtual plans being completely abandoned.

Figure 2.

Representation of adherence to initial virtual surgical plans, divided as complete, partial, or abandoned.

The reasons for incomplete adherence or abandonment of virtual surgical plan are listed in Figure 3. Among free flap operations necessitating VSP, complete adherence to the initial plan was made difficult by rapid tumor growth (n = 1) and altered patient extremity anatomy (n = 1). The patient with rapid tumor growth had mandibular resections outside the planned cutting guide and therefore required intraoperative alterations. Partial adherence occurred in another patient who had had polio induced atrophy of her fibula and therefore required adjustments when the standardized fibula cutting guide was applied in vivo. In a third patient, the large cutting guides caused excessive tissue dissection and skin necrosis of her native skin flaps, whereas in another case, a peroneus magnus was found during leg dissection. In both of these cases, the virtual surgery was adhered to, however, with difficulty.

Figure 3.

List of reasons explaining incomplete adherence or abandonment of initial virtual surgical plans.

Among the orthognathic cases, abandonment of the VSP could be explained by condyles out of centric relation on initial scan (n = 1) and soft tissue redraping that precluded the need for genioplasty (n = 1). Incomplete adherence was caused by restricted mandibular movement by soft tissues with difficulty placing the genioplasty (n = 1), difficulty in positioning chin with downfracture (n = 1), inadequate cutting guides due to engineering error (n = 1), and chipped tooth on occlusal splint model (n = 1).