Craniomaxillofacial Free Flap Reconstruction Using Virtual Surgical Planning

  • James Leighton Mayo
  • Hugo St. Hilaire


Through the evolution of microsurgery, imaging techniques, and CAD-CAM technology, virtual surgical planning (VSP) has become a routine tool for reconstructive microsurgeons. Its application can aid in improved operative efficiency as well as more accurate and consistent results. To realize the full potential of VSP, well-structured and detailed planning must occur. Data is gathered via thinly sliced CT scans of both the donor site and the site of reconstruction. A team-oriented planning session then ensues, mapping out the area of extirpation and outlining the goals of reconstruction. Finally, the surgery is executed in a consistently efficient manner using prefabricated surgical models, cutting guides, and, at times, pre-bent plates. The result is a more efficient surgery with predictably more accurate results. This chapter will fully outline the key components to integrating VSP into head and neck reconstruction.

The applications for VSP within head and neck reconstruction are numerous. A strong working knowledge of the bone flaps available for reconstruction is advantageous when faced with varied reconstructive challenges. The fibula, iliac, scapular, and radial bone flaps are outlined in this chapter with a description of the pertinent anatomy, pearls for flap harvest, and application to specific reconstructive areas. Finally, key concepts for site-specific reconstruction are presented including mandible, maxilla, orbito-maxilla, and fronto-orbital units. With a solid understanding of VSP planning and execution, various bone flaps for reconstruction, and site-specific key concepts, the head and neck reconstructive surgeon can provide predictably favorable results in an efficient manner.


Mandibular reconstruction Maxillary reconstruction Fronto-orbital reconstruction Virtual surgical planning CAD-CAM technology Patient-specific plate 


  1. 1.
    Wei F-C, Chen H-C, Chuang C-C, Noordhoff MS. Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg. 1986;78(2):191–9.CrossRefGoogle Scholar
  2. 2.
    Hidalgo DA. Fibular free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84(1):71–9.CrossRefGoogle Scholar
  3. 3.
    Cutting C, Bookstein FL, Grayson B, Fellingham L, McCarthy JG. Three-dimensional computer-assisted design of craniofacial surgical procedures: optimization and interaction with cephalometric and CT-based models. Plast Reconstr Surg. 1986;77(6):877–85.CrossRefGoogle Scholar
  4. 4.
    Rose EH, Norris MS, Rosen JM. Application of high-tech three-dimensional imaging and computer-generated models in complex facial reconstructions with vascularized bone grafts. Plast Reconstr Surg. 1993;91(2):252–64.CrossRefGoogle Scholar
  5. 5.
    Hirsch DL, Garfein ES, Christensen AM, Weimer KA, Saddeh PB, Levine JP. Use of computer-aided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction. J Oral Maxillofac Surg. 2009;67:2115–22.CrossRefGoogle Scholar
  6. 6.
    Saad A, Winters R, Wise MW, Dupin CL, St-Hilaire H. Virtual surgical planning in complex composite maxillofacial reconstruction. Plast Reconstr Surg. 2013;132(3):626–31.CrossRefGoogle Scholar
  7. 7.
    Levine JP, Bae JS, Soares M, Brecht LE, Saadeh PB, Ceradini DJ, Hirsch DL. Jaw in a day: total maxillofacial reconstruction using digital technology. Plast Reconstr Surg. 2013;131(6):1386–91.CrossRefGoogle Scholar
  8. 8.
    Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg. 1975;55(5):533–44.CrossRefGoogle Scholar
  9. 9.
    Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg. 1994;93(2):294–304.CrossRefGoogle Scholar
  10. 10.
    Momoh AO, Yu P, Skoracki RJ, Liu S, Feng L, Hanasono MM. A prospective cohort study of fibula free flap donor-site morbidity in 157 consecutive patients. Plast Reconstr Surg. 2011;128(3):714–20.CrossRefGoogle Scholar
  11. 11.
    Yang GF, Chen PJ, Gao YZ, Liu XY, Li J, Jiang SX, et al. Forearm free skin flap transplantation: a report of 56 cases. 1981. Br J Plast Surg. 1997;50(3):162–5.CrossRefGoogle Scholar
  12. 12.
    Zenn MR, Hidalgo DA, Cordeiro PG, Shah JP, Strong EW, Kraus DH. Current role of the radial forearm free flap in mandibular reconstruction. Plast Reconstr Surg. 1997;99(4):1012–7.CrossRefGoogle Scholar
  13. 13.
    Timmons MJ, Missotten FE, Poole MD, Davies DM. Complications of radial forearm flap donor sites. Br J Plast Surg. 1986;39(2):176–8.CrossRefGoogle Scholar
  14. 14.
    Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg. 1990;86(2):287–92.CrossRefGoogle Scholar
  15. 15.
    Vaughan ED. The radial forearm free flap in orofacial reconstruction. Personal experience in 120 consecutive cases. J Craniomaxillofac Surg. 1990;18(1):2–7.CrossRefGoogle Scholar
  16. 16.
    Avery CME. Review of the radial free flap: still evolving or facing extinction? Part two: osteocutaneous radial free flap. Br J Oral Maxillofac Surg. 2010;48(4):253–60.CrossRefGoogle Scholar
  17. 17.
    Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. 2000;105(7):2331–46.CrossRefGoogle Scholar
  18. 18.
    Timmons MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg. 1986;77(1):80–92.CrossRefGoogle Scholar
  19. 19.
    Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg. 1979;64(6):1745–59.CrossRefGoogle Scholar
  20. 20.
    Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V. The free vascularised iliac crest tissue transfer: donor site complications associated with eighty-two cases. Br J Plast Surg. 1992;45(2):89–93.CrossRefGoogle Scholar
  21. 21.
    Kimata Y, Uchiyama K, Sakuraba M, Ebihara S, Hayashi R, Asakage T, Nakatsuka T, Harii K. Deep circumflex iliac perforator flap with iliac crest for mandibular reconstruction. Br J Plast Surg. 2001;54(6):487–90.CrossRefGoogle Scholar
  22. 22.
    Brown JS, Jones DC, Summerwill A, Rogers SN, Howell RA, Cawood JI, Vaughan ED. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg. 2002;40(3):183–90.CrossRefGoogle Scholar
  23. 23.
    Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg. 1986;77(4):530–45.CrossRefGoogle Scholar
  24. 24.
    Gibber MJ, Clain JB, Jacobson AS, et al. Subscapular system of flaps: an 8-year experience with 105 patients. Head Neck. 2015;37(8):1200–6.CrossRefGoogle Scholar
  25. 25.
    Dowthwaite SA, Theurer J, Belzile M, Fung K, Franklin J, Nichols A, et al. Comparison of fibular and scapular osseous free flaps for oromandibular reconstruction: a patient-centered approach to flap selection. JAMA Otolaryngol Head Neck Surg. 2013;139(3):285–92.CrossRefGoogle Scholar
  26. 26.
    Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg. 1984;37(4):574–6.CrossRefGoogle Scholar
  27. 27.
    Dos Santos LF. The vascular anatomy and dissection of the free scapular flap. Plast Reconstr Surg. 1984;73(4):599–603.CrossRefGoogle Scholar
  28. 28.
    Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg. 1982;69(4):591–600.CrossRefGoogle Scholar
  29. 29.
    Thoma A, Heddle S. The extended free scapular flap. Br J Plast Surg. 1990;43(6):709–12.CrossRefGoogle Scholar
  30. 30.
    Rodriguez ED, Stanwix MG, Nam AJ, St-Hilaire H, Simmons OP, Manson PN. Definitive treatment of persistent frontal sinus infection: elimination of dead space and sinonasal communication. Plast Reconstr Surg. 2009;123(3):957–67.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Aesthetic and Reconstructive Surgery InstituteOrlando Health-University of Florida Cancer Center of OrlandoOrlandoUSA
  2. 2.Division of Plastic & Reconstructive Surgery, Department of SurgeryLouisiana State UniversityNew OrleansUSA

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