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Digital surgery group versus traditional experience group in head and neck reconstruction: a retrospective controlled study to analyze clinical value and time-economic-social effect

Digital surgery group versus traditional experience group in head and neck reconstruction: a... Objective: Discuss the application value of digital surgical technology in the reconstruction of head and neck defects after tumor resection and comprehensively evaluate time-economic-benefit cost. Methods: A retrospective analysis of head and neck cancer patients who underwent reconstructive operations in head and neck surgery at Sichuan Cancer Hospital from January 2015 to January 2021 was performed. According to the inclusion and exclusion criteria, a total of 52 cases were included, including 25 cases using digital surgery (DS) and 27 cases using the conventional surgery (CS). The clinical-pathological characteristics, postoperative complications, functional aesthetic evaluation indexes, and time-cost-satisfaction evaluation indexes between the two groups were compared and statistically analyzed. Typical cases using digital surgery were shared. Results: Outcomes between the two groups were comparable, and there was no significant difference in survival outcome and follow-up time between the two groups (P > 0.05). There was no significant difference between the two groups in the defect size, pathological type, other major clinicopathological features, or operation-related indicators (P > 0.05). The incidence of titanium plate displacement, deformation or exposure, and facial scar deformity in the DS group was significantly lower than that in the CS group (P < 0.05). However, there was no significant difference in other short-term or long-term complications (P > 0.05). The incidence of dysphagia and eating disorders in the DS group was significantly reduced (P < 0.05). The speech and social functions were improved, but not significantly (P > 0.05). Meanwhile, there was no significant difference in the evaluation index of facial aesthetics in this study (P > 0.05). Furthermore, the total operation time, preparation time of bone flap from the donor site, osteotomy time, and recon- struction time in the DS group were significantly lower than those in the traditional operation group (P < 0.05), but *Correspondence: zjq-wkys@163.com; headneck@qq.com Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu 610041, China Department of Head and Neck Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 2 of 15 the shaping time and vascular anastomosis time of recipient area could not be shortened (P > 0.05). In addition, there was no significant difference in total hospitalization days between the DS group and CS group (P > 0.05), but the time of ICU treatment and postoperative intravenous nutrition support in the DS group were shorter than those in the CS group (P < 0.05). In particular, the preoperative doctor-patient communication of the DS group was more effective, and the treatment satisfaction of patients including their families was higher after operation (P < 0.05). Conclusion: Comprehensive application of digital surgical technology (CAD, CAM, VR, MA, etc.) in the reconstruction of the head and neck after tumor resection is feasible in clinical practice, which can not only improve the accuracy of repair, decrease some surgical complications, better preserve and improve patient’s diet and speech function, and reduce the operation and hospitalization time, but also increase the treatment cost. Furthermore, it is conducive to doctor-patient communication and improves patient satisfaction. Keywords: Head and neck tumors, Digital surgical technique, Reconstruction Introduction three-dimensional physical model for clinicians, visual The anatomical position of the head and neck is unique, surgical design and simulation before operation, assist- with complex functional areas, especially the oral cavity, ing in the production of complex surgical schemes, as an important organ of speech, swallowing, and facial and quantitative evaluation of surgical effect after sur - contours of the human body, which occupies a pivotal gery. Through intraoperative navigation technology, the position. The purpose of reconstruction after head and operation can be carried out accurately according to neck tumor resection is not only to restore the anatomy the preoperative design. In recent years, with its rapid but also more important to retain its proper physiologi- development, many studies [5–7] have proved that the cal function. Especially when the tumor infiltrates hard application of the above technology has an important tissue such as the maxilla and mandible, the defect after auxiliary role in the repair and reconstruction of head resection not only affects the appearance of patients, but and neck tumors after surgical resection. It can assist also causes physiological dysfunction in chewing, swal- in the design and operation of head and neck surgery, lowing, and speech, which seriously affects the quality improve the quality of 3D reconstruction, improve the of life and social activities of patients, resulting in heavy accuracy of navigation or guide plate-assisted surgery, psychological burden and mental pressure. With the con- control the negative surgical margin, and reduce iatro- cept of personalized and functional reconstruction, peo- genic injury. It can improve the accuracy of maxillofacial ple put forward higher requirements for the functional repair, enhance the accuracy of operation, save operation recovery of postoperative appearance and occlusion [1]. time, and improve the curative effect. This gives full play The traditional repair method is mainly made by sur - to the characteristics of evidence-based, quantitative, vis- geons according to the imaging data and clinical exami- ualization and controllable of precision surgery. nation results. During the operation, autogenous bone In recent years, our department mainly used three- transplantation and vascularized free flap repair are car - dimensional reconstruction, CAD/CAM technology, VR, ried out according to the experience of the surgeons. This and MR to assist the whole process of surgical treatment treatment method is an “experience dependent” treat- of head and neck tumors involving maxillary and man- ment process, which lacks personalized design and accu- dibular reconstruction and achieved significant clinical rate surgical guidance. The treatment process depends results [8]. The aim of this study was to comprehensively on the surgeon’s experience and skill level. Therefore, it evaluate the effectiveness, accuracy, and economy of is difficult to repair these defects accurately at the ana - these digital techniques in assisting head and neck tomical level and restore their original physiological reconstruction. functions. Digital surgery (DS) includes three-dimensional recon- Materials and methods struction, computer-aided design (CAD), computer- Clinical materials aided manufacturing (CAM), 3D printing technology, A retrospective analysis was conducted on the patients image-guided surgical navigation, virtual reality (VR), who underwent head and neck tumor resection and augmented reality (AR), and mixed reality (MR) and reconstruction in the department of head and neck sur- other advanced digital technologies integrated with tra- gery of Sichuan Cancer Center from January 2015 to ditional surgery. This is a new technology based on the June 2021. According to the inclusion and exclusion cri- continuous development and progress of information teria, 52 patients with complete data were included in technology [2–4]. Its advantages include providing a the study. Based on whether digital surgical techniques Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 3 of 15 were used or not, they were further divided into the than 70 years old. (5) Follow-up time less than 6 months digital surgery group (DS group) and the conventional or loss of follow-up. (6) Presence of other severe basic surgery group (CS). Among them, 25 patients in the DS diseases affecting the operation or prognosis of patients. group chose applicable digital surgical technology to assist the implementation of repairment and reconstruc- The application process of digital surgical technology tion according to the nature, scope, and location of the Before operation, thin-layer CT scanning was performed lesions. Three-dimensional visualization technology on the lesion area to obtain the image data of the lesion was used in all patients of this group, to evaluate tumor location and determine the extent of the lesion tissue. and operation risk and to stimulate the operation plan. The data in DICOM format is used for linear interpola - At the same time, 3D printing technology was used to tion to construct a 3D image. After that, median filter - make equal scale models for preoperative evaluation, ing and image enhancement were carried out on the 3D doctor-patient communication, pre-bending titanium, reconstruction image, and the computer 3D visualiza- and osteotomy plate. Then, precise osteotomy, titanium tion reconstruction was carried out (Fig.  1A, B). Then, plate fixation, and molding were carried out during the the data is transmitted to the rapid prototyping system operation. For some cases with tumor involving impor- in STL format. The rapid prototyping machine uses tant blood vessels, nerves, and tissue structure, VR was its own layering software to relayer and complete the used to evaluate the invasion range and safe boundary of contour editing and molding support setting of the fill - operation before operation. During the operation, MR ings. Then, the CAD/CAM image technology is used technology was used to accurately locate the tumor posi- to transform the healthy side data into a symmetrical tion and judge the adjacent anatomical relationship of the model of the affected side, which is the reference image tumor, the distance between the surgical instruments and model after restoration. Finally, the photosensitive resin the tumor, and the scope of surgical resection. In the CS is used to reconstruct the model. Molecular polylactic group, 27 patients underwent empirical reconstruction acid (PLA) was used as the raw material to produce a based on preoperative two-dimensional imaging evalu- three-dimensional individualized solid model, bone flap ation and intraoperative subjective judgment. The main solid model, and osteotomy plate based on the principle epidemiological information and clinicopathological fea- of “layered manufacturing and layer by layer superposi- tures of the two groups are shown in Table 1. tion” (Fig. 1C). The resected lesion range was determined according to the above-mentioned three-dimensional Inclusion and exclusion criteria reconstruction data and the solid model. The length of Inclusion criteria are as follows: (1) All cases are patients the reconstruction titanium plate and the fixed position with head and neck tumors requiring surgery. (2) Path- of the titanium nail were determined according to the ological types are squamous cell carcinoma, sarcoma, virtual operation range and osteotomy plate, the length ameloblastoma, and other diseases requiring surgical of the donor site, and the design and molding of the resection. (3) Four groups of surgeons with similar clini- bone flap. Then, the reconstruction titanium plate was cal working years and similar surgical techniques. (4) pre-bent on the mirror model of the solid model, so as Free fibula, iliac bone, rib, or other free flaps were used to prepare the bone extraction, shaping, positioning, and for head and neck reconstruction in stage I after primary fixation according to the template shape during the oper - tumor resection. (5) Microsurgical vascular anastomosis ation (Fig.  1D–F). According to the simulated occlusal was performed at least twice and a vascular stapler was relationship between the upper and lower teeth and the used at most one time. (6) CAD, 3D printing, VR, AR, or jaw plane, the wax shape was prepared to restore the MR techniques were performed in the DS group. (7) The dentition in the jaw defect area. The working model was data of included cases were collected and sorted for anal- turned over and the digital occlusal guide plate was made ysis. (8) All cases were followed up for at least 6 months. by pressing film rapid prototyping (Fig. 2). (9) Patients may have other basic complications (such For patients who need VR, AR, or MR assistance, the as diabetes, high blood pressure, etc.) that do not affect DICOM images are further tested to ensure that the the operation process. (10) There was no other adjuvant images meet quality standards. After special process- therapy except less than 2 times of neoadjuvant chemo- ing of privacy-related data information in these digital therapy before operation. pictures, DICOM images were segmented according Exclusion criteria are as follows: (1) Patients with unre- to different anatomical regions, and the segmented sectable head and neck tumors. (2) The operation process images were reconstructed according to the opera- did not involve the reconstruction of a free bone flap or tion requirements. CT and MRI images were fused skin flap. (3) Incomplete data collection and collation of by multimodal modeling. The accuracy of the multi - the included cases. (4) Age less than 18 years old or more modal model is tested by medical imaging experts. The Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 4 of 15 Table 1 Baseline clinicopathological characteristics of the comparison of parameters between two groups of patients Variable Digital surgery-assisted (n = 25) Conventional surgery (n = 27) P-value Mean age (years) 45.7 48.8 0.52 Gender 0.10 Male 11 18 Female 14 9 Pathological type 0.09 Squamous cell carcinoma 7 12 Sarcoma 3 8 Ameloblastoma 7 3 Others 8 4 Lesion location 0.29 Maxilla 3 8 Mandible 19 16 Maxillofacial soft tissue 3 3 Flap selection 0.19 Free fibula 12 8 Free ilium 9 10 Floating rib 1 0 Composite reconstruction 3 9 Coexisting other conditions or diseases 0.51 Yes 17 16 No 8 11 Neck dissection 17 15 0.35 Re-exploration 7 9 0.68 Adjuvant therapy 0.27 Yes 9 6 No 16 21 Smokers 10 15 0.26 Number of osteotomies (mean) 2.16 2.03 0.54 ≤1 4 7 0.67 2 13 12 ≥3 8 8 Defect range (cm, mean) 6.20 5.74 0.36 Follow-up (months, mean) 32.8 39.1 0.42 Survival outcome 0.12 Living 22 19 Deceased 3 8 multimodal three-dimensional reconstruction model is computer control to match and fuse the virtual model transformed into a VR model, and the important struc- with the patient’s head lesions, so as to quickly locate tures such as the blood vessel, nerve, bone, and tumor the body surface projection of the tumor location are rendered in different colors to facilitate the identi - in the virtual scene using gesture operations to pick fication of parts. The rendered model is imported into up, rotate, scale, split, or profile VR or AR operations a UE4 engine to realize the function customization. (Fig.  2). During the operation, the surgeons can judge By installing cluster rendering equipment, 3D scanner, the adjacent anatomic relationship of the tumor, the and 3D scene scanner and wearing a head-mounted distance between surgical instruments, and the tumor display and data glove, surgeons observe the virtual or the degree of resection in real time to implement model through holographic VR glasses and use a tablet tumor resection (Fig. 2). Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 5 of 15 Fig. 1 A Three-dimensional reconstruction of maxillary lesions by computer simulation. B Reconstruction of mandible lesions by computer simulation. C 3D printing individual solid model, bone flap solid model, and osteotomy plate. D Osteotomy according to the osteotomy guide plate. E Design and shaping of the bone flap. F The pre-bent titanium plate and pre-determined position of the titanium nail were used for rigid internal fixation Fig. 2 During the operation, the operator can judge the surrounding adjacent and anatomic relationship of tumor, the distance between surgical instruments and tumor, and the degree of tumor resection Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 6 of 15 Evaluating indicator EORTC QLQ-H&N Module [9]. In addition, the post- The location of lesion, pathological type, skin flap selec - operative functional and aesthetic indexes of the two tion, complications, osteotomy times, defect range, fol- groups were comprehensively evaluated (Table  3). The low-up time, and survival outcome of the two groups subjective evaluation index was mainly conducted by were statistically analyzed (Table  1). At the same time, doctors, patients, and family members. The final evalu - the short-term and long-term postoperative complica- ation result was agreed upon by more than two people, tions were classified and compared in detail (Table  2). and the EORTC QLQ-H&N Module was also referenced. The evaluation was conducted with reference to the Objective evaluation indexes included condylar displace- ment and mandibular angle displacement. Preopera- tive imaging images were compared with postoperative ones. The displacement exceeding 5mm was considered Table 2 Postoperative complications and morbidities. Data are as deviation. Finally, the time, economic cost, and doc- given as number of complications tor-patient satisfaction of assisted digital surgical tech- Complications Digital surgery- Conventional P-value nology were comprehensively evaluated (Table  4). The assisted (n = (n = 27) satisfaction of the doctor-patient relationship was evalu- 25) ated by the patient-doctor relationship questionnaire-13 Flap hyperemia or 9 8 0.62 (PDRQ-13) [10]. necrosis Titanium plate displace- 3 10 0.03 Statistical analysis ment, deformation, or exposure SPSS 20.0 software was used to test the data. The con - Infection 7 8 0.89 tinuous variables involved in the article were analyzed by Orocutaneous fistula 2 2 0.93 an independent sample t test. Categorical variables were Weight change 14 13 0.57 tested by a chi-square test. P < 0.05 was considered statis- Hematoma 6 9 0.46 tically significant. Scar deformity 4 11 0.04 Constant pain 6 12 0.12 Results Paresthesia 9 11 0.73 Comparison of main clinicopathological features Cough 9 6 0.27 A total of 52 patients were enrolled in this study, includ- Dry mouth 12 9 0.28 ing 25 patients in the DS group and 27 patients in the CS Table 3 Function and aesthetic evaluation of the two group patients. Data are given as number of patients Variable Digital surgery-assisted (n = 25) Conventional (n = 27) P-value Speech 0.09 Ambiguity 2 7 Understandable 14 16 Basically normal 9 4 Swallow 0.04 Total oral intake with no restrictions 4 9 Oral intake with no special preparation, but must avoid 8 13 specific foods Total oral intake with no restrictions 13 5 Eating disorders 6 15 0.03 Social barriers 6 13 0.07 Opening degree 0.37 <20 mm 3 7 20–29 mm 10 11 ≥30 mm 12 9 Condylar shift 4 10 0.09 Gonion shift 9 11 0.73 Malocclusion 7 10 0.49 Facial asymmetry 11 15 0.41 Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 7 of 15 Table 4 Time and cost-analysis of digital surgery comparing between two group patients Variable Unit Digital surgery-assisted Conventional (mean) P-value (mean) Total cost of hospitalization CNY 88,315 67,599 <0.05 Operation cost CNY 14,784 10,380 <0.05 Material cost CNY 31,010 12,819 <0.05 Total operation time Min 458 532 <0.05 Molding time of supply area Min 34.6 42.5 0.01 Shaping time of receiving area Min 17.1 18.7 0.35 Cutting or molding time Min 12.5 15.0 0.02 Reconstruction time Min 29.4 33.9 0.01 Vascular anastomosis time Min 47.1 49.2 0.50 Total days in hospital Days 19.6 18.1 0.27 ICU days Days 1.36 2.55 <0.05 Intravenous nutrition support Days 7.28 10.1 0.04 Satisfaction score of doctor-patient relation- Score 3.48 2.88 0.02 ship group. The average age of the DS group (45.7 years old) no statistically significant difference (P > 0.05), as shown was slightly lower than that of the CS group (48.8 years in Table 2. old), but this difference was not statistically significant. In addition, there were no significant differences in gender, Functional and aesthetic evaluation smoking status, pathological type, lesion distribution, Just by comparison, the incidence of swallowing and eat- complications, or adjuvant treatment between the two ing disorders in patients assisted by digital surgical tech- groups. There were no significant differences in the fac - nology was significantly reduced (P < 0.05). There was tors related to the operation, including the type of flap, some improvement in postoperative speech and social the size of the lesion after resection, neck lymph node function, but the statistical results were not significantly dissection, osteotomy times, and reoperation exploration different (P > 0.05). In terms of facial aesthetic evalua - rate. However, in the mean value of the lesion range after tion, there was no significant difference between the two resection, the DS group (6.2cm) was larger than the CS groups in opening degree, condylar shift, gonion shift, group (5.7cm). In addition, there was no significant dif - malocclusion, and facial asymmetry (P > 0.05). Details ference in survival outcome and follow-up time between are shown in Table 3. the two groups. The results showed that the two groups of patients did not interfere with the main evaluation Time-economic-social benefit evaluation indicators of this study, and the two groups were compa- The results of this study show that patients with digital rable, as shown in Table 1. surgical assist technology have higher total hospitaliza- tion costs, surgical costs, and material costs than the tra- Comparison of complications ditional empirical repair group (P < 0.05). However, the By comparison, only 3 patients in the DS group sup- total operation time, the preparation time of bone flaps plemented with digital surgical techniques experienced in the donor area, osteotomy time, and reconstruction titanium plate displacement, deformation, or exposure, time were significantly lower than the traditional surgery and the incidence was significantly lower than that in the group (P < 0.05), and it could not shorten the shaping conventional empirical repair group (P < 0.05). In addi- time of the receiving area and the time of vascular anas- tion, the incidence of facial scar deformity in the DS tomosis (P > 0.05). In addition, the total hospitalization group was significantly lower than that in the CS group days of the two groups were not obvious differences, (P < 0.05). However, in other short-term or long-term but the time of ICU treatment and the time of postop- postoperative complications (such as flap congestion or erative intravenous nutritional support of patients in the necrosis, infection, orocutaneous fistula, hematoma, DS group are shorter than those of the traditional sur- weight change, persistent pain, paresthesia, cough, and gery group (P < 0.05). It is particularly worth mentioning dry mouth), although some indicators in the DS group that in the process of digital surgical assisted treatment, were slightly lower than those in the CS group, there was due to the presentation of three-dimensional images and Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 8 of 15 3D printed physical models, and even the intervention vessels in the donor site were identified (Fig.  3C). CAD of immersive VR technology, the preoperative doctor- technology combined with 3D printing technology was patient communication of this group of patients is more used to assist in the formulation of the surgical plan. effective, and the treatment satisfaction of patients and According to the mandible defect area and fibula width, their families after surgery is higher (P < 0.05). thickness and angulation data were compared to deter- mine the optimal fibula osteotomy area and to do vir - Typical cases of comprehensive application of 3D tual reconstruction (Fig.  3D). Each cross-section was reconstruction, digital simulation, and 3D printing formed by a 3D printer, and the 3D solid model and technology osteotomy plate were gradually superimposed in pro- The patient, a 21-year-old female, was diagnosed with portion to the lesion site and fibula (Fig.  3C). Accord- bilateral mandibular osteosarcoma 5 years ago. The ing to the reconstructed model of rapid prototyping, patient required radiotherapy with a total dose of 104 titanium plates with suitable length and angle were pre- Gy in twice. Three years ago, the tumor reoccurred and pared before operation. At the same time, the 3D recon- required surgical treatment, and the free rib necrosis struction model image was used to design and 3D print resulted in complete mandibular defect (Fig.  3A). Two the implant restoration guide plate (Fig.  3E). Accord- years ago, she was treated in our hospital for second- ing to the preoperative simulated operation plan, the ary mandibular reconstruction. The treatment plan was right fibular myocutaneous flap free reconstruction of discussed by the multidiscipline team (MDT) several mandible + left lateral femoral transplantation + vas- times before the operation. The maxillofacial and bone cular anastomosis + titanium plate internal fixation three-dimensional reconstruction was performed to + tracheotomy was performed under general anes- evaluate the extent of jaw defect (Fig.  3B). Meanwhile, thesia. The relationship between free fibula and max - the perforators of fibula and anterolateral femoral illa and the position between titanium nail and screws Fig. 3 A Preoperative facial features of patients. B Three-dimensional reconstruction of maxillofacial CT before operation. C The three-dimensional solid model and osteotomy plate of the vascular perforator, lesion site, and fibula. D Computer-aided design to simulate the osteotomy range of fibula flap and mandible reconstruction. E Based on the three-dimensional reconstruction model image, the implant restoration guide plate was designed and 3D printed Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 9 of 15 were determined by an implant reconstruction guide started 1 month after the operation, and the oral liquid plate. After the occlusal relationship was determined, diet was completely consumed after 3 months (Fig. 5A). the titanium plate with suitable length and radian was The examination showed that the reconstructed man - molded and fixed in the predetermined position which dible grew well (Fig. 5B). At present, the patient is cur- was confirmed by computer simulation and 3D physical rently undergoing later functional exercise, and the model before the operation (Fig.  4). The patient recov - opening degree is about 5cm. The dental implant resto - ered well afterwards. A small amount of oral liquid diet ration will be completed in the later. Fig. 4 A Mandibular defects and soft tissue defects were found during the operation. B The relationship between free fibula and maxilla and the position of titanium screws were determined by implant repair guide plate, and then the titanium plate with suitable length and radian was molded and fixed in the predetermined position by using preoperative computer simulation and 3D physical model. C The peroneal flap was used to reconstruct the floor of the mouth, and the lateral femoral flap was used to reconstruct the neck defect. D Status after intraoperative reconstruction. E Intraoral conditions after intraoperative reconstruction Fig. 5 A The gastric tube was removed 3 months after the operation, and the opening was about 5 cm. B Three-dimensional reconstruction of CT scan 3 months after the operation Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 10 of 15 Typical cases using VR, MR, and other techniques to assist lymph node dissection + right lateral femoral free mus- surgical treatment cle flap repair + temporal bone and sphenoid greater A 69-year-old male patient presented with a progres- wing partial resection + zygomatic partial resection + sive mass in the left temporal region. The cytological and dural partial resection + right leg broad ligament dural pathological diagnosis obtained by coarse needle aspira- repair + small blood vessel anastomosis” were performed tion showed malignant solitary fibrous tumor in the left under general anesthesia (Fig.  8). During the operation, temporal region. Enhanced CT and MRI showed that the MR technology was used to locate, split, and monitor the left temporal intracranial and infratemporal fossa areas tumor in real time which can assist the operation safely found irregular soft tissue masses. Bone was destructed (Fig.  7B, C). The patient was discharged from the hos - in the zygomatic process, squama of the left temporal pital 9 days after the operation followed with adjuvant bone, and the greater wing of the sphenoid bone. The treatment, such as radiotherapy and chemotherapy, and lesions may invade the left lateral pterygoid muscle and recovered well. temporal muscle, and the left temporal lobe is com- pressed (Fig.  6A). The three-dimensional reconstruc - Discussion tion showed that the tumor had abundant blood supply, For a long time, the treatment of head and neck tumors with branches of the external carotid artery, especially in has been based on surgery, supplemented by radiother- the periphery, pushing the adjacent left external jugular apy and chemotherapy. In recent years, with the rapid vein and its branches (Fig.  6B–D). Before operation, the development of immunotherapy and targeted therapy, patient was considered to have a complex craniomaxil- the treatment of head and neck tumors has entered lofacial communication tumor. VR technology was used a new era. The comprehensive application of various to communicate with patients accurately, vividly, and means has improved the survival rate of patients and effectively, so that patients could understand their own preserved function greatly. However, due to the low condition, operation purpose, and risk (Fig.  7A). After level of immune expression or the mutation of impor- completing the preoperative examination, “left lateral tant gene loci in some patients, the therapeutic effect of skull base communication tumor resection + left neck new methods is seriously affected [11, 12]. Surgery, as the Fig. 6 A Preoperative enhanced CT and MRI imaging showed the extent of the lesion. B Three-dimensional reconstruction after skin and soft tissue removal. C The relationship between the tumor and adjacent tissues was demonstrated by crypto jaw enucleation and skull transparency. D Saphenous osteotomy showed tumor and important structures (only blood vessels, brain, and nerves). E The tumors and important structures (only blood vessels and nerves) can be shown in the brain tissue Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 11 of 15 Fig. 7 A Preoperative use of MR technology and patients with accurate, effective visual communication between doctors and patients. B-D In the course of the operation, the MR technique was used to locate, split, and monitor the tumor in real time Fig. 8 A Preoperative tumor location and surgical procedure design. B The exposure of primary lesion in operation. C According to the operation plan, the tumor and zygomatic arch were completely removed under the guidance and assistance of MR. D The lateral femoral myocutaneous flap was used to repair the defect in the operation area (the muscle flap was used to fill the lateral skull base, the fascia lata was used to repair the dura mater, and the skin island was used as the observation window of the myocutaneous flap) Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 12 of 15 earliest and most important treatment method, is still the patients before the operation to promote communica- most important factor affecting the therapeutic effect. tion between doctors and patients. Our results also show It has always been the goal of head and neck surgeons that the combination of 3D reconstructed images and 3D to maximize tumor resection and obtain a reliable and printed models can effectively improve the postoperative safe boundary. However, due to its special location and satisfaction of patients. anatomy, it often needs reconstruction when the tumor CAD technology is based on imaging data, which in the is removed from the head and neck. Most small defects digital software for virtual design of surgical process. In can be repaired with adjacent flaps or pedicled flaps our clinical work, we found that in the traditional treat- [13]. Medium and large defects are mainly repaired with ment mode, the resection range of head and neck tumor the pedicled flap and free flap. Although some scholars is usually roughly determined by the operator according have made in-depth research and improvement on the to clinical examination and imaging examination, which pedicled flap in the past to make its indication wider, lacks personalized surgical design. With the prevalence safer, and more reliable [14, 15], the free flap has gradu - of vascularized free tissue flap repair and reconstruction, ally become the main choice for repair and reconstruc- for example, when the tumor area is large and the maxilla tion of these patients because of its unique advantages, and mandible are involved, the appearance of the patients especially when it involves bone tissue reconstruc- is obviously affected. The restoration of the occlusion tion. However, for the free flap, the efficiency and accu - relationship and the three-dimensional position of the racy of traditional reconstruction are not ideal, which grafts are usually determined by the experience of the restricts its clinical application. With the development operator. However, this “experience dependent” position- and application of various digital surgical techniques, the ing method usually lacks sufficient accuracy and stabil - reconstruction after head and neck tumor resection has ity, resulting in inaccurate head and neck reconstruction embarked on a precise and individualized road. and transplantation. If the three-dimensional position of Three-dimensional reconstruction technology is the bone reconstruction is not ideal, it is difficult to obtain cornerstone of digital surgical technology, and it has a a satisfactory occlusal relationship and masticatory func- milestone significance as the beginning of digital tech - tion recovery, and cannot achieve the precise reconstruc- nology. Three-dimensional reconstruction technology tion of personalized function desired appearance. can not only provide intuitive, clear, and specific three- In addition, CAD technology enables doctors to use dimensional tissue images, but also can be controlled by various digital software to carry out tumor resection and doctors through digital software to make them move. reconstruction in the virtual model before the operation. u Th s, doctors can observe the lesions and their adjacent According to the nature and three-dimensional position relationship with the surrounding important anatomical of the tumor, the scope of resection was determined, structures from various angles, which are more intuitive. and especially when bone reconstruction is involved, the Surgeons can also judge the location and range of tumors position of the osteotomy line is designed in the digital so as to determine the safe boundary for tumor resection. software for virtual osteotomy [17]. In particular, the It is obvious that the technology provides strong support mandible has a unique horseshoe-shaped structure. Man- for accurate diagnosis and treatment [16]. dibular tumors usually lead to destruction of the mandi- Three-dimensional reconstruction technology is also ble bone, so it is difficult to restore the normal shape of widely used in clinical practice. It is also one of the ear- the mandible [18]. In the cases of mandibular reconstruc- liest digital technologies applied in our department. At tion we provided, we used CAD technology to simulate present, patients with advanced head and neck malignant the whole mandible before the operation, and restored tumors who need surgical treatment in our department the pre-amputation shape of the mandible according to are treated with three-dimensional reconstruction rou- the data stored in the digital software. According to the tinely when important adjacent tissues or structures of range and location of the defect, the length and angle of the head and neck are involved. In this study, all patients each segment of bone graft were precisely designed to in the DS group used 3D reconstruction technology meet the needs of shape and function repair in a three- before the operation. With this technology, we can accu- dimensional position (Fig. 1A, B). rately reconstruct the three-dimensional structure of the The core of CAM technology is 3D printing technol - head and neck with computer software and judge the ogy. In recent years, there are more and more auxiliary location, range, invasion, and destruction of bone tissue applications in head and neck surgery. This technique is in the 3D reconstruction model. Intuitive three-dimen- one of the important ways to transform the preopera- sional images help the doctor to design the operation and tive design into the actual operation process. At the same implement accurate resection (Fig. 3B). At the same time, time, we can design the osteotomy guide plate, shaping it is helpful for surgeons to explain the operation plan to guide plate, and other surgical guide plates simultaneously Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 13 of 15 while making the virtual design scheme for patients with to wearing a “perspective eye” for doctors. Earlier, our head and neck tumor involving the jaw bone and manu- department took the lead in the application of VR tech- facture the same proportion of real objects through 3D nology in preoperative evaluation and simulation and printing technology. In the process of mandible osteot- achieved some results [20]. Recently, we increased the omy, fibula cutting, and shaping, the corresponding 3D application of MR technology in the reconstruction sur- printing guide plate is used to guide the operation, so as to gery, adjusted the imaging model of the patient, used the transform the preoperative virtual design scheme into the navigation technology embedded matching positioning actual operation. Through this method, we can achieve on the patient, and operated the operation through the the goal of precise resection and accurate reconstruc- panoramic stereo imaging in the AR glasses. Moreover, tion. In addition, according to the preoperative design, with the displacement of the patient’s position during the the reconstruction model of the mandible after fibula or operation, the image can still maintain accurate position- iliac reconstruction can be printed out, and personalized ing to assist the implementation of the precise opera- reconstruction titanium plate can be pre-bent to guide the tion (Fig.  7B, C). After our exploration, we found that accurate restoration of jaw shape and occlusion relation- the main advantages of this kind of technology are (1) ship (Figs. 1C and 3C), which reduces the dependence on the new imaging technology can form embedded three- subjective experience, while simplifying and reducing the dimensional images, which can display the complex soft difficulty of the operation. Some studies [19] compared tissue situation in front of clinicians more intuitively; (2) the coincidence degree between the preoperative design do not need to rely on the doctor’s subjective impression and postoperative actual mandible, fibula osteotomy line, to avoid the surgical risk caused by visual gaps; and (3) and reconstruction titanium plate. It was considered that reflect the osteotomy angle and osteotomy line planned the maximum error of reconstruction came from the before surgery in the operation. manual bending reconstruction titanium plate, which also In addition to the above-mentioned digital surgical tech- proved the reliability of digital surgical technology applied niques commonly used in our department, with the devel- to jaw defect reconstruction. CAD/CAM technology is opment of science, technology, and economy, more and used in most cases in this study. The results of this study more emerging technologies are used for precise repair also show that the pre-bent titanium plate can better and personalized reconstruction of head and neck tumors. shape and reduce the stress of the titanium plate. It also Surgical navigation technology is another effective way reduces the risk of titanium plate displacement, deforma- to transform a virtual design into surgical practice. Com- tion, and exposure after surgery. Patients could obtain pared with the surgical guide plate, the advantage of the better facial appearance and reduce unnecessary broad navigation technology is that it can carry out “real-time” scar. Other surgical-related complications also decreased verification and guidance in a three-dimensional position. from the study results, although there was no statistically The preoperative design of the surgical scheme can not significant difference. only be carried out accurately, but also be flexibly adjusted It must be pointed out that although CAD/CAM tech- according to the actual situation [21]. Three-dimensional nology has many advantages, it still has some shortcom- measurement and evaluation technology can match the ings and limitations in our clinical work. The existing reconstructed jaw model with the ideal designed model CAD technology is mainly based on bone tissue struc- before operation and analyze the reconstruction error by ture, which cannot accurately estimate and judge the chromatographic analysis. The difference of the coordi - influence of soft tissue. Many types of surgical guides are nates and angles of the main landmarks before and after designed based on bone structure. In the actual operation the operation was compared to evaluate the accuracy of process, the influence of soft tissue cannot be ignored. the repair and reconstruction. This method provides a On the one hand, the existence of soft tissue affects the quantitative evaluation standard for the reconstruction preoperative judgment of the tumor range. Once it is effect and can intuitively help the surgeon to find intraop - found that the actual resection range needs to be changed erative problems in order to better advance and improve- during the operation, the surgical guide plate will not be ment [22]. The surgical robot has a “sensing system” and a used; on the other hand, it will affect the fitting degree of “vision system,” which can accurately locate the operation the surgical guide plate and bone tissue, which will affect position according to the preoperative design. In recent the accuracy of the operation to a certain extent. years, it has been used in a variety of head and neck sur- In order to accurately estimate and judge the influ - gery and achieved a good therapeutic effect [23]. However, ence of soft tissue and solve the above problems, VR, AR, there are few reports on the reconstruction of jaw defects. and MR techniques have been gradually used in head In recent years, it has been reported that the model and and neck surgery in recent years. These technologies animal experiment of robot-assisted free fibula flap for can provide “perspective function,” which is equivalent mandibular defect repair [24]. The experimental results Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 14 of 15 Abbreviations show that the repair accuracy of the surgical robot is sig- DS: Digital surgery; CS: Conventional surgery; CAD: Computer-aided design; nificantly better than that of traditional surgery, which CAM: Computer-aided manufacturing; VR: Virtual reality; AR: Augmented confirms the application value and advantages of surgical reality; MR: Mixed reality. robots in mandibular reconstruction surgery. Acknowledgements The application of these digital surgical technologies can We would like to express our gratitude to all those who helped our group dur- not only ensure the safety of surgery, reduce the difficulty ing the writing of this thesis. Thanks to Michelle Z. Malouta for modifying the language of the article. Our deepest gratitude to Professor Jingqiang Zhu and of surgery, improve the effect of repair, and facilitate the Chao Li for funding and support. postoperative function, but also shorten the process of sur- gery and the recovery time of patients to a certain extent. Authors’ contributions (I) Conception and design: R Sun, C Li, and J Zhu; (II) administrative support: However, it must be pointed out that our research results R Sun, C Li, and J Zhu; (III) provision of study materials or patients: X Wang, show that due to the high equipment cost, material cost, Y Zhou, and Y Cai; (IV ) collection and assembly of data: Y Cai, C Shui, and X and labor cost of these technologies, although they have Wang; ( V ) data analysis and interpretation: Y Cai, Y Zhou, and C Shui; ( VI) manuscript writing: all authors; ( VII) final approval of manuscript: all authors; many advantages and can save the time cost of doctors ( VIII) language modification: Michelle Z. Malouta. and patients, this approach also significantly increases the cost of surgery and hospitalization for patients. There - Funding 1. ZX2019008l; Project of Health and Health Commission of Sichuan Province fore, in the process of clinical application, we can not only 2. ZX2019016; Project of Chengdu Science and Technology Bureau consider the advantages of the technology itself, but also 3. 2019YFS0329; Key research and development projects of Sichuan Provincial combine the patient’s own situation and economic condi- Department of Science and Technology tions to selectively use effective digital technology. After Availability of data and materials all, compared with conventional experience repair, most of The datasets used or analyzed during the current study are available from the the indicators in this study, especially in the repair effect corresponding authors on reasonable request. and the incidence of complications, have shown certain advantages, but there is no significant statistical differ - Declarations ence. Of course, the limited sample size and retrospective Ethics approval and consent to participate research methods limit the stability and reliability of the The research program was approved by the ethics committee of the Sichuan research results. At the same time, the development of dig- Cancer Hospital (SCCHEC-02-2021-005). All participants and patients agreed to participate in this research program. ital technology has a process, so there may be differences in the time sequence and social status of patients. In order Consent for publication to obtain more specific, accurate, and comprehensive eval - All authors consent to publish. All presentations of case reports have been given consent to publish by the persons themselves. uation results, we need to further carry out large sample randomized controlled trials to verify. It is safe to say that Competing interests under the guidance of the concept of precision medicine, The authors declare that they have no competing interests. with the development of digital technology and the efforts Author details of clinicians, the level of head and neck reconstruction is Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan bound to be raised to a new height. University, Chengdu 610041, China. Department of Head and Neck Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China. Department of Psychiatry, Bloomington Mead- Conclusion ows Hospital, 3600 N Prow Rd, Bloomington, IN 47404, USA. Depar tment of Head and Neck Surgery, Chengdu Renpin Otolaryngology Hospital, Comprehensive application of digital surgical technol- Chengdu 610000, China. ogy in the reconstruction of the head and neck after tumor resection is feasible in clinical practice, which can Received: 14 August 2021 Accepted: 29 April 2022 not only improve the accuracy of repair, decrease some surgical complications, better preserve and improve the patient’s diet and speech function, and reduce the opera- References tion and hospitalization time, but also increase the treat- 1. Yuan X, Xuan M, Tian W, et al. Application of digital surgical guides in ment cost. Furthermore, it is conducive to doctor-patient mandibular resection and reconstruction with fibula flaps. Int J Oral communication and improves patient satisfaction. Digital Maxillofac Surg. 2016;45(11):1406–9. 2. Rybicki FJ. 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Digital surgery group versus traditional experience group in head and neck reconstruction: a retrospective controlled study to analyze clinical value and time-economic-social effect

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Abstract

Objective: Discuss the application value of digital surgical technology in the reconstruction of head and neck defects after tumor resection and comprehensively evaluate time-economic-benefit cost. Methods: A retrospective analysis of head and neck cancer patients who underwent reconstructive operations in head and neck surgery at Sichuan Cancer Hospital from January 2015 to January 2021 was performed. According to the inclusion and exclusion criteria, a total of 52 cases were included, including 25 cases using digital surgery (DS) and 27 cases using the conventional surgery (CS). The clinical-pathological characteristics, postoperative complications, functional aesthetic evaluation indexes, and time-cost-satisfaction evaluation indexes between the two groups were compared and statistically analyzed. Typical cases using digital surgery were shared. Results: Outcomes between the two groups were comparable, and there was no significant difference in survival outcome and follow-up time between the two groups (P > 0.05). There was no significant difference between the two groups in the defect size, pathological type, other major clinicopathological features, or operation-related indicators (P > 0.05). The incidence of titanium plate displacement, deformation or exposure, and facial scar deformity in the DS group was significantly lower than that in the CS group (P < 0.05). However, there was no significant difference in other short-term or long-term complications (P > 0.05). The incidence of dysphagia and eating disorders in the DS group was significantly reduced (P < 0.05). The speech and social functions were improved, but not significantly (P > 0.05). Meanwhile, there was no significant difference in the evaluation index of facial aesthetics in this study (P > 0.05). Furthermore, the total operation time, preparation time of bone flap from the donor site, osteotomy time, and recon- struction time in the DS group were significantly lower than those in the traditional operation group (P < 0.05), but *Correspondence: zjq-wkys@163.com; headneck@qq.com Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu 610041, China Department of Head and Neck Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 2 of 15 the shaping time and vascular anastomosis time of recipient area could not be shortened (P > 0.05). In addition, there was no significant difference in total hospitalization days between the DS group and CS group (P > 0.05), but the time of ICU treatment and postoperative intravenous nutrition support in the DS group were shorter than those in the CS group (P < 0.05). In particular, the preoperative doctor-patient communication of the DS group was more effective, and the treatment satisfaction of patients including their families was higher after operation (P < 0.05). Conclusion: Comprehensive application of digital surgical technology (CAD, CAM, VR, MA, etc.) in the reconstruction of the head and neck after tumor resection is feasible in clinical practice, which can not only improve the accuracy of repair, decrease some surgical complications, better preserve and improve patient’s diet and speech function, and reduce the operation and hospitalization time, but also increase the treatment cost. Furthermore, it is conducive to doctor-patient communication and improves patient satisfaction. Keywords: Head and neck tumors, Digital surgical technique, Reconstruction Introduction three-dimensional physical model for clinicians, visual The anatomical position of the head and neck is unique, surgical design and simulation before operation, assist- with complex functional areas, especially the oral cavity, ing in the production of complex surgical schemes, as an important organ of speech, swallowing, and facial and quantitative evaluation of surgical effect after sur - contours of the human body, which occupies a pivotal gery. Through intraoperative navigation technology, the position. The purpose of reconstruction after head and operation can be carried out accurately according to neck tumor resection is not only to restore the anatomy the preoperative design. In recent years, with its rapid but also more important to retain its proper physiologi- development, many studies [5–7] have proved that the cal function. Especially when the tumor infiltrates hard application of the above technology has an important tissue such as the maxilla and mandible, the defect after auxiliary role in the repair and reconstruction of head resection not only affects the appearance of patients, but and neck tumors after surgical resection. It can assist also causes physiological dysfunction in chewing, swal- in the design and operation of head and neck surgery, lowing, and speech, which seriously affects the quality improve the quality of 3D reconstruction, improve the of life and social activities of patients, resulting in heavy accuracy of navigation or guide plate-assisted surgery, psychological burden and mental pressure. With the con- control the negative surgical margin, and reduce iatro- cept of personalized and functional reconstruction, peo- genic injury. It can improve the accuracy of maxillofacial ple put forward higher requirements for the functional repair, enhance the accuracy of operation, save operation recovery of postoperative appearance and occlusion [1]. time, and improve the curative effect. This gives full play The traditional repair method is mainly made by sur - to the characteristics of evidence-based, quantitative, vis- geons according to the imaging data and clinical exami- ualization and controllable of precision surgery. nation results. During the operation, autogenous bone In recent years, our department mainly used three- transplantation and vascularized free flap repair are car - dimensional reconstruction, CAD/CAM technology, VR, ried out according to the experience of the surgeons. This and MR to assist the whole process of surgical treatment treatment method is an “experience dependent” treat- of head and neck tumors involving maxillary and man- ment process, which lacks personalized design and accu- dibular reconstruction and achieved significant clinical rate surgical guidance. The treatment process depends results [8]. The aim of this study was to comprehensively on the surgeon’s experience and skill level. Therefore, it evaluate the effectiveness, accuracy, and economy of is difficult to repair these defects accurately at the ana - these digital techniques in assisting head and neck tomical level and restore their original physiological reconstruction. functions. Digital surgery (DS) includes three-dimensional recon- Materials and methods struction, computer-aided design (CAD), computer- Clinical materials aided manufacturing (CAM), 3D printing technology, A retrospective analysis was conducted on the patients image-guided surgical navigation, virtual reality (VR), who underwent head and neck tumor resection and augmented reality (AR), and mixed reality (MR) and reconstruction in the department of head and neck sur- other advanced digital technologies integrated with tra- gery of Sichuan Cancer Center from January 2015 to ditional surgery. This is a new technology based on the June 2021. According to the inclusion and exclusion cri- continuous development and progress of information teria, 52 patients with complete data were included in technology [2–4]. Its advantages include providing a the study. Based on whether digital surgical techniques Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 3 of 15 were used or not, they were further divided into the than 70 years old. (5) Follow-up time less than 6 months digital surgery group (DS group) and the conventional or loss of follow-up. (6) Presence of other severe basic surgery group (CS). Among them, 25 patients in the DS diseases affecting the operation or prognosis of patients. group chose applicable digital surgical technology to assist the implementation of repairment and reconstruc- The application process of digital surgical technology tion according to the nature, scope, and location of the Before operation, thin-layer CT scanning was performed lesions. Three-dimensional visualization technology on the lesion area to obtain the image data of the lesion was used in all patients of this group, to evaluate tumor location and determine the extent of the lesion tissue. and operation risk and to stimulate the operation plan. The data in DICOM format is used for linear interpola - At the same time, 3D printing technology was used to tion to construct a 3D image. After that, median filter - make equal scale models for preoperative evaluation, ing and image enhancement were carried out on the 3D doctor-patient communication, pre-bending titanium, reconstruction image, and the computer 3D visualiza- and osteotomy plate. Then, precise osteotomy, titanium tion reconstruction was carried out (Fig.  1A, B). Then, plate fixation, and molding were carried out during the the data is transmitted to the rapid prototyping system operation. For some cases with tumor involving impor- in STL format. The rapid prototyping machine uses tant blood vessels, nerves, and tissue structure, VR was its own layering software to relayer and complete the used to evaluate the invasion range and safe boundary of contour editing and molding support setting of the fill - operation before operation. During the operation, MR ings. Then, the CAD/CAM image technology is used technology was used to accurately locate the tumor posi- to transform the healthy side data into a symmetrical tion and judge the adjacent anatomical relationship of the model of the affected side, which is the reference image tumor, the distance between the surgical instruments and model after restoration. Finally, the photosensitive resin the tumor, and the scope of surgical resection. In the CS is used to reconstruct the model. Molecular polylactic group, 27 patients underwent empirical reconstruction acid (PLA) was used as the raw material to produce a based on preoperative two-dimensional imaging evalu- three-dimensional individualized solid model, bone flap ation and intraoperative subjective judgment. The main solid model, and osteotomy plate based on the principle epidemiological information and clinicopathological fea- of “layered manufacturing and layer by layer superposi- tures of the two groups are shown in Table 1. tion” (Fig. 1C). The resected lesion range was determined according to the above-mentioned three-dimensional Inclusion and exclusion criteria reconstruction data and the solid model. The length of Inclusion criteria are as follows: (1) All cases are patients the reconstruction titanium plate and the fixed position with head and neck tumors requiring surgery. (2) Path- of the titanium nail were determined according to the ological types are squamous cell carcinoma, sarcoma, virtual operation range and osteotomy plate, the length ameloblastoma, and other diseases requiring surgical of the donor site, and the design and molding of the resection. (3) Four groups of surgeons with similar clini- bone flap. Then, the reconstruction titanium plate was cal working years and similar surgical techniques. (4) pre-bent on the mirror model of the solid model, so as Free fibula, iliac bone, rib, or other free flaps were used to prepare the bone extraction, shaping, positioning, and for head and neck reconstruction in stage I after primary fixation according to the template shape during the oper - tumor resection. (5) Microsurgical vascular anastomosis ation (Fig.  1D–F). According to the simulated occlusal was performed at least twice and a vascular stapler was relationship between the upper and lower teeth and the used at most one time. (6) CAD, 3D printing, VR, AR, or jaw plane, the wax shape was prepared to restore the MR techniques were performed in the DS group. (7) The dentition in the jaw defect area. The working model was data of included cases were collected and sorted for anal- turned over and the digital occlusal guide plate was made ysis. (8) All cases were followed up for at least 6 months. by pressing film rapid prototyping (Fig. 2). (9) Patients may have other basic complications (such For patients who need VR, AR, or MR assistance, the as diabetes, high blood pressure, etc.) that do not affect DICOM images are further tested to ensure that the the operation process. (10) There was no other adjuvant images meet quality standards. After special process- therapy except less than 2 times of neoadjuvant chemo- ing of privacy-related data information in these digital therapy before operation. pictures, DICOM images were segmented according Exclusion criteria are as follows: (1) Patients with unre- to different anatomical regions, and the segmented sectable head and neck tumors. (2) The operation process images were reconstructed according to the opera- did not involve the reconstruction of a free bone flap or tion requirements. CT and MRI images were fused skin flap. (3) Incomplete data collection and collation of by multimodal modeling. The accuracy of the multi - the included cases. (4) Age less than 18 years old or more modal model is tested by medical imaging experts. The Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 4 of 15 Table 1 Baseline clinicopathological characteristics of the comparison of parameters between two groups of patients Variable Digital surgery-assisted (n = 25) Conventional surgery (n = 27) P-value Mean age (years) 45.7 48.8 0.52 Gender 0.10 Male 11 18 Female 14 9 Pathological type 0.09 Squamous cell carcinoma 7 12 Sarcoma 3 8 Ameloblastoma 7 3 Others 8 4 Lesion location 0.29 Maxilla 3 8 Mandible 19 16 Maxillofacial soft tissue 3 3 Flap selection 0.19 Free fibula 12 8 Free ilium 9 10 Floating rib 1 0 Composite reconstruction 3 9 Coexisting other conditions or diseases 0.51 Yes 17 16 No 8 11 Neck dissection 17 15 0.35 Re-exploration 7 9 0.68 Adjuvant therapy 0.27 Yes 9 6 No 16 21 Smokers 10 15 0.26 Number of osteotomies (mean) 2.16 2.03 0.54 ≤1 4 7 0.67 2 13 12 ≥3 8 8 Defect range (cm, mean) 6.20 5.74 0.36 Follow-up (months, mean) 32.8 39.1 0.42 Survival outcome 0.12 Living 22 19 Deceased 3 8 multimodal three-dimensional reconstruction model is computer control to match and fuse the virtual model transformed into a VR model, and the important struc- with the patient’s head lesions, so as to quickly locate tures such as the blood vessel, nerve, bone, and tumor the body surface projection of the tumor location are rendered in different colors to facilitate the identi - in the virtual scene using gesture operations to pick fication of parts. The rendered model is imported into up, rotate, scale, split, or profile VR or AR operations a UE4 engine to realize the function customization. (Fig.  2). During the operation, the surgeons can judge By installing cluster rendering equipment, 3D scanner, the adjacent anatomic relationship of the tumor, the and 3D scene scanner and wearing a head-mounted distance between surgical instruments, and the tumor display and data glove, surgeons observe the virtual or the degree of resection in real time to implement model through holographic VR glasses and use a tablet tumor resection (Fig. 2). Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 5 of 15 Fig. 1 A Three-dimensional reconstruction of maxillary lesions by computer simulation. B Reconstruction of mandible lesions by computer simulation. C 3D printing individual solid model, bone flap solid model, and osteotomy plate. D Osteotomy according to the osteotomy guide plate. E Design and shaping of the bone flap. F The pre-bent titanium plate and pre-determined position of the titanium nail were used for rigid internal fixation Fig. 2 During the operation, the operator can judge the surrounding adjacent and anatomic relationship of tumor, the distance between surgical instruments and tumor, and the degree of tumor resection Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 6 of 15 Evaluating indicator EORTC QLQ-H&N Module [9]. In addition, the post- The location of lesion, pathological type, skin flap selec - operative functional and aesthetic indexes of the two tion, complications, osteotomy times, defect range, fol- groups were comprehensively evaluated (Table  3). The low-up time, and survival outcome of the two groups subjective evaluation index was mainly conducted by were statistically analyzed (Table  1). At the same time, doctors, patients, and family members. The final evalu - the short-term and long-term postoperative complica- ation result was agreed upon by more than two people, tions were classified and compared in detail (Table  2). and the EORTC QLQ-H&N Module was also referenced. The evaluation was conducted with reference to the Objective evaluation indexes included condylar displace- ment and mandibular angle displacement. Preopera- tive imaging images were compared with postoperative ones. The displacement exceeding 5mm was considered Table 2 Postoperative complications and morbidities. Data are as deviation. Finally, the time, economic cost, and doc- given as number of complications tor-patient satisfaction of assisted digital surgical tech- Complications Digital surgery- Conventional P-value nology were comprehensively evaluated (Table  4). The assisted (n = (n = 27) satisfaction of the doctor-patient relationship was evalu- 25) ated by the patient-doctor relationship questionnaire-13 Flap hyperemia or 9 8 0.62 (PDRQ-13) [10]. necrosis Titanium plate displace- 3 10 0.03 Statistical analysis ment, deformation, or exposure SPSS 20.0 software was used to test the data. The con - Infection 7 8 0.89 tinuous variables involved in the article were analyzed by Orocutaneous fistula 2 2 0.93 an independent sample t test. Categorical variables were Weight change 14 13 0.57 tested by a chi-square test. P < 0.05 was considered statis- Hematoma 6 9 0.46 tically significant. Scar deformity 4 11 0.04 Constant pain 6 12 0.12 Results Paresthesia 9 11 0.73 Comparison of main clinicopathological features Cough 9 6 0.27 A total of 52 patients were enrolled in this study, includ- Dry mouth 12 9 0.28 ing 25 patients in the DS group and 27 patients in the CS Table 3 Function and aesthetic evaluation of the two group patients. Data are given as number of patients Variable Digital surgery-assisted (n = 25) Conventional (n = 27) P-value Speech 0.09 Ambiguity 2 7 Understandable 14 16 Basically normal 9 4 Swallow 0.04 Total oral intake with no restrictions 4 9 Oral intake with no special preparation, but must avoid 8 13 specific foods Total oral intake with no restrictions 13 5 Eating disorders 6 15 0.03 Social barriers 6 13 0.07 Opening degree 0.37 <20 mm 3 7 20–29 mm 10 11 ≥30 mm 12 9 Condylar shift 4 10 0.09 Gonion shift 9 11 0.73 Malocclusion 7 10 0.49 Facial asymmetry 11 15 0.41 Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 7 of 15 Table 4 Time and cost-analysis of digital surgery comparing between two group patients Variable Unit Digital surgery-assisted Conventional (mean) P-value (mean) Total cost of hospitalization CNY 88,315 67,599 <0.05 Operation cost CNY 14,784 10,380 <0.05 Material cost CNY 31,010 12,819 <0.05 Total operation time Min 458 532 <0.05 Molding time of supply area Min 34.6 42.5 0.01 Shaping time of receiving area Min 17.1 18.7 0.35 Cutting or molding time Min 12.5 15.0 0.02 Reconstruction time Min 29.4 33.9 0.01 Vascular anastomosis time Min 47.1 49.2 0.50 Total days in hospital Days 19.6 18.1 0.27 ICU days Days 1.36 2.55 <0.05 Intravenous nutrition support Days 7.28 10.1 0.04 Satisfaction score of doctor-patient relation- Score 3.48 2.88 0.02 ship group. The average age of the DS group (45.7 years old) no statistically significant difference (P > 0.05), as shown was slightly lower than that of the CS group (48.8 years in Table 2. old), but this difference was not statistically significant. In addition, there were no significant differences in gender, Functional and aesthetic evaluation smoking status, pathological type, lesion distribution, Just by comparison, the incidence of swallowing and eat- complications, or adjuvant treatment between the two ing disorders in patients assisted by digital surgical tech- groups. There were no significant differences in the fac - nology was significantly reduced (P < 0.05). There was tors related to the operation, including the type of flap, some improvement in postoperative speech and social the size of the lesion after resection, neck lymph node function, but the statistical results were not significantly dissection, osteotomy times, and reoperation exploration different (P > 0.05). In terms of facial aesthetic evalua - rate. However, in the mean value of the lesion range after tion, there was no significant difference between the two resection, the DS group (6.2cm) was larger than the CS groups in opening degree, condylar shift, gonion shift, group (5.7cm). In addition, there was no significant dif - malocclusion, and facial asymmetry (P > 0.05). Details ference in survival outcome and follow-up time between are shown in Table 3. the two groups. The results showed that the two groups of patients did not interfere with the main evaluation Time-economic-social benefit evaluation indicators of this study, and the two groups were compa- The results of this study show that patients with digital rable, as shown in Table 1. surgical assist technology have higher total hospitaliza- tion costs, surgical costs, and material costs than the tra- Comparison of complications ditional empirical repair group (P < 0.05). However, the By comparison, only 3 patients in the DS group sup- total operation time, the preparation time of bone flaps plemented with digital surgical techniques experienced in the donor area, osteotomy time, and reconstruction titanium plate displacement, deformation, or exposure, time were significantly lower than the traditional surgery and the incidence was significantly lower than that in the group (P < 0.05), and it could not shorten the shaping conventional empirical repair group (P < 0.05). In addi- time of the receiving area and the time of vascular anas- tion, the incidence of facial scar deformity in the DS tomosis (P > 0.05). In addition, the total hospitalization group was significantly lower than that in the CS group days of the two groups were not obvious differences, (P < 0.05). However, in other short-term or long-term but the time of ICU treatment and the time of postop- postoperative complications (such as flap congestion or erative intravenous nutritional support of patients in the necrosis, infection, orocutaneous fistula, hematoma, DS group are shorter than those of the traditional sur- weight change, persistent pain, paresthesia, cough, and gery group (P < 0.05). It is particularly worth mentioning dry mouth), although some indicators in the DS group that in the process of digital surgical assisted treatment, were slightly lower than those in the CS group, there was due to the presentation of three-dimensional images and Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 8 of 15 3D printed physical models, and even the intervention vessels in the donor site were identified (Fig.  3C). CAD of immersive VR technology, the preoperative doctor- technology combined with 3D printing technology was patient communication of this group of patients is more used to assist in the formulation of the surgical plan. effective, and the treatment satisfaction of patients and According to the mandible defect area and fibula width, their families after surgery is higher (P < 0.05). thickness and angulation data were compared to deter- mine the optimal fibula osteotomy area and to do vir - Typical cases of comprehensive application of 3D tual reconstruction (Fig.  3D). Each cross-section was reconstruction, digital simulation, and 3D printing formed by a 3D printer, and the 3D solid model and technology osteotomy plate were gradually superimposed in pro- The patient, a 21-year-old female, was diagnosed with portion to the lesion site and fibula (Fig.  3C). Accord- bilateral mandibular osteosarcoma 5 years ago. The ing to the reconstructed model of rapid prototyping, patient required radiotherapy with a total dose of 104 titanium plates with suitable length and angle were pre- Gy in twice. Three years ago, the tumor reoccurred and pared before operation. At the same time, the 3D recon- required surgical treatment, and the free rib necrosis struction model image was used to design and 3D print resulted in complete mandibular defect (Fig.  3A). Two the implant restoration guide plate (Fig.  3E). Accord- years ago, she was treated in our hospital for second- ing to the preoperative simulated operation plan, the ary mandibular reconstruction. The treatment plan was right fibular myocutaneous flap free reconstruction of discussed by the multidiscipline team (MDT) several mandible + left lateral femoral transplantation + vas- times before the operation. The maxillofacial and bone cular anastomosis + titanium plate internal fixation three-dimensional reconstruction was performed to + tracheotomy was performed under general anes- evaluate the extent of jaw defect (Fig.  3B). Meanwhile, thesia. The relationship between free fibula and max - the perforators of fibula and anterolateral femoral illa and the position between titanium nail and screws Fig. 3 A Preoperative facial features of patients. B Three-dimensional reconstruction of maxillofacial CT before operation. C The three-dimensional solid model and osteotomy plate of the vascular perforator, lesion site, and fibula. D Computer-aided design to simulate the osteotomy range of fibula flap and mandible reconstruction. E Based on the three-dimensional reconstruction model image, the implant restoration guide plate was designed and 3D printed Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 9 of 15 were determined by an implant reconstruction guide started 1 month after the operation, and the oral liquid plate. After the occlusal relationship was determined, diet was completely consumed after 3 months (Fig. 5A). the titanium plate with suitable length and radian was The examination showed that the reconstructed man - molded and fixed in the predetermined position which dible grew well (Fig. 5B). At present, the patient is cur- was confirmed by computer simulation and 3D physical rently undergoing later functional exercise, and the model before the operation (Fig.  4). The patient recov - opening degree is about 5cm. The dental implant resto - ered well afterwards. A small amount of oral liquid diet ration will be completed in the later. Fig. 4 A Mandibular defects and soft tissue defects were found during the operation. B The relationship between free fibula and maxilla and the position of titanium screws were determined by implant repair guide plate, and then the titanium plate with suitable length and radian was molded and fixed in the predetermined position by using preoperative computer simulation and 3D physical model. C The peroneal flap was used to reconstruct the floor of the mouth, and the lateral femoral flap was used to reconstruct the neck defect. D Status after intraoperative reconstruction. E Intraoral conditions after intraoperative reconstruction Fig. 5 A The gastric tube was removed 3 months after the operation, and the opening was about 5 cm. B Three-dimensional reconstruction of CT scan 3 months after the operation Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 10 of 15 Typical cases using VR, MR, and other techniques to assist lymph node dissection + right lateral femoral free mus- surgical treatment cle flap repair + temporal bone and sphenoid greater A 69-year-old male patient presented with a progres- wing partial resection + zygomatic partial resection + sive mass in the left temporal region. The cytological and dural partial resection + right leg broad ligament dural pathological diagnosis obtained by coarse needle aspira- repair + small blood vessel anastomosis” were performed tion showed malignant solitary fibrous tumor in the left under general anesthesia (Fig.  8). During the operation, temporal region. Enhanced CT and MRI showed that the MR technology was used to locate, split, and monitor the left temporal intracranial and infratemporal fossa areas tumor in real time which can assist the operation safely found irregular soft tissue masses. Bone was destructed (Fig.  7B, C). The patient was discharged from the hos - in the zygomatic process, squama of the left temporal pital 9 days after the operation followed with adjuvant bone, and the greater wing of the sphenoid bone. The treatment, such as radiotherapy and chemotherapy, and lesions may invade the left lateral pterygoid muscle and recovered well. temporal muscle, and the left temporal lobe is com- pressed (Fig.  6A). The three-dimensional reconstruc - Discussion tion showed that the tumor had abundant blood supply, For a long time, the treatment of head and neck tumors with branches of the external carotid artery, especially in has been based on surgery, supplemented by radiother- the periphery, pushing the adjacent left external jugular apy and chemotherapy. In recent years, with the rapid vein and its branches (Fig.  6B–D). Before operation, the development of immunotherapy and targeted therapy, patient was considered to have a complex craniomaxil- the treatment of head and neck tumors has entered lofacial communication tumor. VR technology was used a new era. The comprehensive application of various to communicate with patients accurately, vividly, and means has improved the survival rate of patients and effectively, so that patients could understand their own preserved function greatly. However, due to the low condition, operation purpose, and risk (Fig.  7A). After level of immune expression or the mutation of impor- completing the preoperative examination, “left lateral tant gene loci in some patients, the therapeutic effect of skull base communication tumor resection + left neck new methods is seriously affected [11, 12]. Surgery, as the Fig. 6 A Preoperative enhanced CT and MRI imaging showed the extent of the lesion. B Three-dimensional reconstruction after skin and soft tissue removal. C The relationship between the tumor and adjacent tissues was demonstrated by crypto jaw enucleation and skull transparency. D Saphenous osteotomy showed tumor and important structures (only blood vessels, brain, and nerves). E The tumors and important structures (only blood vessels and nerves) can be shown in the brain tissue Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 11 of 15 Fig. 7 A Preoperative use of MR technology and patients with accurate, effective visual communication between doctors and patients. B-D In the course of the operation, the MR technique was used to locate, split, and monitor the tumor in real time Fig. 8 A Preoperative tumor location and surgical procedure design. B The exposure of primary lesion in operation. C According to the operation plan, the tumor and zygomatic arch were completely removed under the guidance and assistance of MR. D The lateral femoral myocutaneous flap was used to repair the defect in the operation area (the muscle flap was used to fill the lateral skull base, the fascia lata was used to repair the dura mater, and the skin island was used as the observation window of the myocutaneous flap) Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 12 of 15 earliest and most important treatment method, is still the patients before the operation to promote communica- most important factor affecting the therapeutic effect. tion between doctors and patients. Our results also show It has always been the goal of head and neck surgeons that the combination of 3D reconstructed images and 3D to maximize tumor resection and obtain a reliable and printed models can effectively improve the postoperative safe boundary. However, due to its special location and satisfaction of patients. anatomy, it often needs reconstruction when the tumor CAD technology is based on imaging data, which in the is removed from the head and neck. Most small defects digital software for virtual design of surgical process. In can be repaired with adjacent flaps or pedicled flaps our clinical work, we found that in the traditional treat- [13]. Medium and large defects are mainly repaired with ment mode, the resection range of head and neck tumor the pedicled flap and free flap. Although some scholars is usually roughly determined by the operator according have made in-depth research and improvement on the to clinical examination and imaging examination, which pedicled flap in the past to make its indication wider, lacks personalized surgical design. With the prevalence safer, and more reliable [14, 15], the free flap has gradu - of vascularized free tissue flap repair and reconstruction, ally become the main choice for repair and reconstruc- for example, when the tumor area is large and the maxilla tion of these patients because of its unique advantages, and mandible are involved, the appearance of the patients especially when it involves bone tissue reconstruc- is obviously affected. The restoration of the occlusion tion. However, for the free flap, the efficiency and accu - relationship and the three-dimensional position of the racy of traditional reconstruction are not ideal, which grafts are usually determined by the experience of the restricts its clinical application. With the development operator. However, this “experience dependent” position- and application of various digital surgical techniques, the ing method usually lacks sufficient accuracy and stabil - reconstruction after head and neck tumor resection has ity, resulting in inaccurate head and neck reconstruction embarked on a precise and individualized road. and transplantation. If the three-dimensional position of Three-dimensional reconstruction technology is the bone reconstruction is not ideal, it is difficult to obtain cornerstone of digital surgical technology, and it has a a satisfactory occlusal relationship and masticatory func- milestone significance as the beginning of digital tech - tion recovery, and cannot achieve the precise reconstruc- nology. Three-dimensional reconstruction technology tion of personalized function desired appearance. can not only provide intuitive, clear, and specific three- In addition, CAD technology enables doctors to use dimensional tissue images, but also can be controlled by various digital software to carry out tumor resection and doctors through digital software to make them move. reconstruction in the virtual model before the operation. u Th s, doctors can observe the lesions and their adjacent According to the nature and three-dimensional position relationship with the surrounding important anatomical of the tumor, the scope of resection was determined, structures from various angles, which are more intuitive. and especially when bone reconstruction is involved, the Surgeons can also judge the location and range of tumors position of the osteotomy line is designed in the digital so as to determine the safe boundary for tumor resection. software for virtual osteotomy [17]. In particular, the It is obvious that the technology provides strong support mandible has a unique horseshoe-shaped structure. Man- for accurate diagnosis and treatment [16]. dibular tumors usually lead to destruction of the mandi- Three-dimensional reconstruction technology is also ble bone, so it is difficult to restore the normal shape of widely used in clinical practice. It is also one of the ear- the mandible [18]. In the cases of mandibular reconstruc- liest digital technologies applied in our department. At tion we provided, we used CAD technology to simulate present, patients with advanced head and neck malignant the whole mandible before the operation, and restored tumors who need surgical treatment in our department the pre-amputation shape of the mandible according to are treated with three-dimensional reconstruction rou- the data stored in the digital software. According to the tinely when important adjacent tissues or structures of range and location of the defect, the length and angle of the head and neck are involved. In this study, all patients each segment of bone graft were precisely designed to in the DS group used 3D reconstruction technology meet the needs of shape and function repair in a three- before the operation. With this technology, we can accu- dimensional position (Fig. 1A, B). rately reconstruct the three-dimensional structure of the The core of CAM technology is 3D printing technol - head and neck with computer software and judge the ogy. In recent years, there are more and more auxiliary location, range, invasion, and destruction of bone tissue applications in head and neck surgery. This technique is in the 3D reconstruction model. Intuitive three-dimen- one of the important ways to transform the preopera- sional images help the doctor to design the operation and tive design into the actual operation process. At the same implement accurate resection (Fig. 3B). At the same time, time, we can design the osteotomy guide plate, shaping it is helpful for surgeons to explain the operation plan to guide plate, and other surgical guide plates simultaneously Sun  et al. World Journal of Surgical Oncology (2022) 20:220 Page 13 of 15 while making the virtual design scheme for patients with to wearing a “perspective eye” for doctors. Earlier, our head and neck tumor involving the jaw bone and manu- department took the lead in the application of VR tech- facture the same proportion of real objects through 3D nology in preoperative evaluation and simulation and printing technology. In the process of mandible osteot- achieved some results [20]. Recently, we increased the omy, fibula cutting, and shaping, the corresponding 3D application of MR technology in the reconstruction sur- printing guide plate is used to guide the operation, so as to gery, adjusted the imaging model of the patient, used the transform the preoperative virtual design scheme into the navigation technology embedded matching positioning actual operation. Through this method, we can achieve on the patient, and operated the operation through the the goal of precise resection and accurate reconstruc- panoramic stereo imaging in the AR glasses. Moreover, tion. In addition, according to the preoperative design, with the displacement of the patient’s position during the the reconstruction model of the mandible after fibula or operation, the image can still maintain accurate position- iliac reconstruction can be printed out, and personalized ing to assist the implementation of the precise opera- reconstruction titanium plate can be pre-bent to guide the tion (Fig.  7B, C). After our exploration, we found that accurate restoration of jaw shape and occlusion relation- the main advantages of this kind of technology are (1) ship (Figs. 1C and 3C), which reduces the dependence on the new imaging technology can form embedded three- subjective experience, while simplifying and reducing the dimensional images, which can display the complex soft difficulty of the operation. Some studies [19] compared tissue situation in front of clinicians more intuitively; (2) the coincidence degree between the preoperative design do not need to rely on the doctor’s subjective impression and postoperative actual mandible, fibula osteotomy line, to avoid the surgical risk caused by visual gaps; and (3) and reconstruction titanium plate. It was considered that reflect the osteotomy angle and osteotomy line planned the maximum error of reconstruction came from the before surgery in the operation. manual bending reconstruction titanium plate, which also In addition to the above-mentioned digital surgical tech- proved the reliability of digital surgical technology applied niques commonly used in our department, with the devel- to jaw defect reconstruction. CAD/CAM technology is opment of science, technology, and economy, more and used in most cases in this study. The results of this study more emerging technologies are used for precise repair also show that the pre-bent titanium plate can better and personalized reconstruction of head and neck tumors. shape and reduce the stress of the titanium plate. It also Surgical navigation technology is another effective way reduces the risk of titanium plate displacement, deforma- to transform a virtual design into surgical practice. Com- tion, and exposure after surgery. Patients could obtain pared with the surgical guide plate, the advantage of the better facial appearance and reduce unnecessary broad navigation technology is that it can carry out “real-time” scar. Other surgical-related complications also decreased verification and guidance in a three-dimensional position. from the study results, although there was no statistically The preoperative design of the surgical scheme can not significant difference. only be carried out accurately, but also be flexibly adjusted It must be pointed out that although CAD/CAM tech- according to the actual situation [21]. Three-dimensional nology has many advantages, it still has some shortcom- measurement and evaluation technology can match the ings and limitations in our clinical work. The existing reconstructed jaw model with the ideal designed model CAD technology is mainly based on bone tissue struc- before operation and analyze the reconstruction error by ture, which cannot accurately estimate and judge the chromatographic analysis. The difference of the coordi - influence of soft tissue. Many types of surgical guides are nates and angles of the main landmarks before and after designed based on bone structure. In the actual operation the operation was compared to evaluate the accuracy of process, the influence of soft tissue cannot be ignored. the repair and reconstruction. This method provides a On the one hand, the existence of soft tissue affects the quantitative evaluation standard for the reconstruction preoperative judgment of the tumor range. Once it is effect and can intuitively help the surgeon to find intraop - found that the actual resection range needs to be changed erative problems in order to better advance and improve- during the operation, the surgical guide plate will not be ment [22]. The surgical robot has a “sensing system” and a used; on the other hand, it will affect the fitting degree of “vision system,” which can accurately locate the operation the surgical guide plate and bone tissue, which will affect position according to the preoperative design. In recent the accuracy of the operation to a certain extent. years, it has been used in a variety of head and neck sur- In order to accurately estimate and judge the influ - gery and achieved a good therapeutic effect [23]. However, ence of soft tissue and solve the above problems, VR, AR, there are few reports on the reconstruction of jaw defects. and MR techniques have been gradually used in head In recent years, it has been reported that the model and and neck surgery in recent years. These technologies animal experiment of robot-assisted free fibula flap for can provide “perspective function,” which is equivalent mandibular defect repair [24]. The experimental results Sun et al. World Journal of Surgical Oncology (2022) 20:220 Page 14 of 15 Abbreviations show that the repair accuracy of the surgical robot is sig- DS: Digital surgery; CS: Conventional surgery; CAD: Computer-aided design; nificantly better than that of traditional surgery, which CAM: Computer-aided manufacturing; VR: Virtual reality; AR: Augmented confirms the application value and advantages of surgical reality; MR: Mixed reality. robots in mandibular reconstruction surgery. Acknowledgements The application of these digital surgical technologies can We would like to express our gratitude to all those who helped our group dur- not only ensure the safety of surgery, reduce the difficulty ing the writing of this thesis. Thanks to Michelle Z. Malouta for modifying the language of the article. Our deepest gratitude to Professor Jingqiang Zhu and of surgery, improve the effect of repair, and facilitate the Chao Li for funding and support. postoperative function, but also shorten the process of sur- gery and the recovery time of patients to a certain extent. Authors’ contributions (I) Conception and design: R Sun, C Li, and J Zhu; (II) administrative support: However, it must be pointed out that our research results R Sun, C Li, and J Zhu; (III) provision of study materials or patients: X Wang, show that due to the high equipment cost, material cost, Y Zhou, and Y Cai; (IV ) collection and assembly of data: Y Cai, C Shui, and X and labor cost of these technologies, although they have Wang; ( V ) data analysis and interpretation: Y Cai, Y Zhou, and C Shui; ( VI) manuscript writing: all authors; ( VII) final approval of manuscript: all authors; many advantages and can save the time cost of doctors ( VIII) language modification: Michelle Z. Malouta. and patients, this approach also significantly increases the cost of surgery and hospitalization for patients. There - Funding 1. ZX2019008l; Project of Health and Health Commission of Sichuan Province fore, in the process of clinical application, we can not only 2. ZX2019016; Project of Chengdu Science and Technology Bureau consider the advantages of the technology itself, but also 3. 2019YFS0329; Key research and development projects of Sichuan Provincial combine the patient’s own situation and economic condi- Department of Science and Technology tions to selectively use effective digital technology. After Availability of data and materials all, compared with conventional experience repair, most of The datasets used or analyzed during the current study are available from the the indicators in this study, especially in the repair effect corresponding authors on reasonable request. and the incidence of complications, have shown certain advantages, but there is no significant statistical differ - Declarations ence. Of course, the limited sample size and retrospective Ethics approval and consent to participate research methods limit the stability and reliability of the The research program was approved by the ethics committee of the Sichuan research results. At the same time, the development of dig- Cancer Hospital (SCCHEC-02-2021-005). All participants and patients agreed to participate in this research program. ital technology has a process, so there may be differences in the time sequence and social status of patients. In order Consent for publication to obtain more specific, accurate, and comprehensive eval - All authors consent to publish. All presentations of case reports have been given consent to publish by the persons themselves. uation results, we need to further carry out large sample randomized controlled trials to verify. It is safe to say that Competing interests under the guidance of the concept of precision medicine, The authors declare that they have no competing interests. with the development of digital technology and the efforts Author details of clinicians, the level of head and neck reconstruction is Department of Thyroid & Parathyroid Surgery, West China Hospital, Sichuan bound to be raised to a new height. University, Chengdu 610041, China. Department of Head and Neck Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China. Department of Psychiatry, Bloomington Mead- Conclusion ows Hospital, 3600 N Prow Rd, Bloomington, IN 47404, USA. Depar tment of Head and Neck Surgery, Chengdu Renpin Otolaryngology Hospital, Comprehensive application of digital surgical technol- Chengdu 610000, China. ogy in the reconstruction of the head and neck after tumor resection is feasible in clinical practice, which can Received: 14 August 2021 Accepted: 29 April 2022 not only improve the accuracy of repair, decrease some surgical complications, better preserve and improve the patient’s diet and speech function, and reduce the opera- References tion and hospitalization time, but also increase the treat- 1. Yuan X, Xuan M, Tian W, et al. Application of digital surgical guides in ment cost. Furthermore, it is conducive to doctor-patient mandibular resection and reconstruction with fibula flaps. Int J Oral communication and improves patient satisfaction. Digital Maxillofac Surg. 2016;45(11):1406–9. 2. Rybicki FJ. 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Journal

World Journal of Surgical Oncology – Springer Journals

Published: Jun 30, 2022

Keywords: Head and neck tumors; Digital surgical technique; Reconstruction

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