Image data based reconstruction of the midface using a patient-specific implant in combination with a vascularized osteomyocutaneous scapular flap.

BACKGROUND: Secondary reconstructions in case of complex craniofacial defects of the midface, following radical tumour surgery, often require individualized surgical techniques. To achieve a satisfying functional and aesthetic outcome various anatomical aspects have to be considered such as the architecture of the bony structures as well as the very special shape of the orbit. Bone grafting is particularly challenging under these conditions, and one single graft type can hardly fulfil all anatomical demands. The presented method aims at combining a free microvascular bone graft and a preoperatively planned patient-specific alloplastic implant which takes into account all anatomic requirements as well as a functional rehabilitation including dental restoration.

CASE REPORT: By means of the described treatment approach, complex midfacial defects are reconstructed on the base of preoperative computer-assisted three-dimensional planning, a patient-specific prefabricated implant and a free vascularized bone transplant. A three-dimensional planning platform was used to create a mirror image of the unaffected contralateral side that was superimposed on the defect side referring to a virtual sagittal plane. The planned donor site of the scapula was then virtually matched into an ideal anatomic position considering all functional and aesthetical aspects, including a later implant based prosthodontic rehabilitation. By use of these virtual outlines, an individual titanium implant was manufactured to provide both for midfacial support and a graft fixture in a position, which was close to original. Intraoperative optical navigation was used to assess the accurate position of the implant with special regard to a correct reconstruction of the orbit. An implantologic rehabilitation could be achieved.

CONCLUSION: The technique presented offers an ideal combination of a patient-specific alloplastic implant for the reconstruction of the very demanding orbital anatomy in combination with a scapular flap offering a sufficient bone stock for an implant based prosthodontic rehabilitation.