Purpose: Virtual surgical planning (VSP) has significantly transformed craniomaxillofacial surgery over the past 2 decades, leading to diverse applications and improved surgical outcomes. However, variations in technological approaches, clinical outcomes, and economic implications persist. This review aims to comprehensively examine the evolution of VSP in craniomaxillofacial surgery, assess its impact on surgical precision and patient outcomes, and identify current trends and future directions. A synthesis of current knowledge is essential to establish evidence-based guidelines for VSP implementation and optimize patient care in this rapidly advancing field.
Methods: A systematic literature search was conducted in PubMed, Embase, and IEEE Xplore databases from their inception to September 2024. Search terms included combinations of "virtual surgical planning" OR "computer-assisted surgery" AND "craniomaxillofacial" OR "maxillofacial" OR "craniofacial" AND "evolution" OR "development" OR "advancement". From 540 initially identified articles, studies focusing on VSP in craniomaxillofacial surgery that reported technological advancements, surgical outcomes, or precision metrics were included. Eligible studies comprised case series with 5 or more subjects, comparative studies, and validation studies. Data extraction included study characteristics, technology details, surgical applications, outcome measures, and economic factors. Quality assessment was performed using appropriate tools based on study design.
Results: Out of 540 articles, 36 studies spanning from 1999 to 2024 met the inclusion criteria. The evolution of VSP was categorized into 3 phases: early foundations (1999 to 2004), expansion of applications and improved accuracy (2005 to 2014), and advanced integration with emerging technologies (2015 to 2024). Orthognathic surgery was the commonest application (52.8% of studies), followed by tumor resection and reconstruction (22.2%). Studies consistently demonstrated smaller linear discrepancies between planned and actual outcomes with VSP compared to conventional methods (VSP: 0.04 to 0.25 mm vs conventional: 0.29 to 1.33 mm). Recent advancements include the integration of artificial intelligence, mixed reality, and robotic systems, enhancing both preoperative planning and intraoperative guidance.
Conclusion: VSP has considerably evolved in craniomaxillofacial surgery, improving accuracy as demonstrated by reduced linear discrepancies between planned and actual outcomes across various procedures. While promising, challenges remain, including the need for standardization, comprehensive cost-effectiveness analyses, and long-term outcome studies.
Background: Midface reconstruction poses challenges due to significant blood loss and difficulty in achieving intraoperative hemostasis, often necessitating blood transfusions. Various agents, most notably tranexamic acid (TXA), have been utilized intraoperatively to mitigate this risk of bleeding and transfusion-related complications.
Purpose: The study purpose was to measure the association of TXA with blood loss and transfusion requirements during craniofacial procedures involving the midface.
Study design, setting, sample: This project was designed as a retrospective cohort study. Patients who underwent midface reconstruction at Children's Hospital Los Angeles between 2010 and 2023 were included, and a retrospective chart review was conducted.
Independent variable: The independent variable was weight-adjusted TXA exposure divided into 2 groups: subjects who received TXA preoperatively and intraoperatively and those that did not.
Main outcome variables: The main outcome variables were weight-adjusted intraoperative blood loss and transfusion requirements. Secondary outcomes included intraoperative and postoperative complications and length of stay.
Covariates: Demographic covariates included age at surgery, sex, weight, and syndromic status. Operative covariates covered the type of surgical approach and main procedure performed. Perioperative covariates included anesthesia time and operative time.
Analyses: Parametric and nonparametric variables were analyzed using independent t-test and Wilcoxon rank-sum test, respectively. χ2 analysis was used to analyze categorical variables, and multivariable linear regressions were performed. A P value of less than .05 was considered statistically significant.
Results: A total of 80 patients underwent midface reconstruction surgery, 37 (46.3%) of whom received TXA and 43(53.7%) did not. The mean age at surgery was 8.7 ± 3.8 years in the TXA cohort and 11.6 ± 5.1 years in the non-TXA cohort (P = .02). Multivariable regression analysis further demonstrated a statistically significant association between the administration of TXA and both reduced blood loss (coefficient -0.14 [95% CI -0.20 to -0.07], P < .01) as well as reduced transfusion requirement (coefficient -0.14 [95% CI -0.19 to -0.08], P < .01). There was no increased risk of complications, such as thromboembolic events or seizures, in patients who were administered TXA (P = .14).
Conclusion and relevance: TXA is likely a valuable adjunct for improving intraoperative and postoperative outcomes of craniofacial procedures involving the midface.
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