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Virtual Surgical Planning Flattens The Learning Curve For Free Fibula Flaps: A Comparative Analysis Between Junior And Senior Attendings In 561 Cases
J. Michael Smith, MD1, Luke Grome, MD2, Jordan Kaplan, MD2, Alexander F. Mericli, MD3, Rene D. Largo, MD3, Z-Hye Lee, MD3, Jun Liu, PhD3, Patrick B. Garvey, MD3.
1The University of Texas Medical Branch, Galveston, TX, USA, 2Baylor College of Medicine, Houston, TX, USA, 3MD Anderson Cancer Center, Houston, TX, USA.

PURPOSE: Most microsurgeons consider the osteocutaneous free fibula flap to not only be the workhouse flap for mandible reconstruction, but to also be one of the most challenging operations to perform. Virtual surgical planning (VSP) has gained popularity because it appears to improve outcomes and lessen the technical difficulty of the reconstruction. We hypothesized that utilization of VSP would help to improve mandibular reconstruction outcomes for less experienced surgeons.
METHODS: After IRB approval, we retrospectively reviewed a database of all free fibula flaps for mandibular reconstruction from April 2005 through October 2019. We compared patient demographics, case specific information, and post-operative outcomes for the VSP versus the free-hand (non-VSP) reconstructions. Faculty surgeons at our institution were stratified into junior versus senior attending cohorts based on whether they had less than or greater than five years’ experience at the time of the reconstruction. Post-operative outcomes were then compared between junior and senior attending cohorts with and without the use of VSP.
RESULTS: 561 patients met inclusion criteria. 180 patients underwent VSP reconstruction by a senior attending, 154 patients underwent non-VSP reconstruction by a senior attending, 60 patients underwent VSP reconstruction by a junior attending, and 167 patients underwent non-VSP reconstruction by a junior attending. Attending seniority was significantly associated with the use of VSP (p < 0.001). When VSP was not utilized, senior attendings achieved a greater rate of first union within one year (74.7% vs. 62.9%, p = 0.017) and experienced a higher rate of full union (56.5% vs. 39.5%, p < 0.001) compared to junior attendings. When VSP was utilized, there was no difference in the rate of first union within one year (83.9% vs. 76.7%, p = 0.403) or the rate of full union (52.2% vs. 51.7%, p = 0.323) between junior and senior attendings. For senior attendings, the use of VSP did not significantly affect the rate of first union within one year (83.9% vs. 74.7%, p = 0.068) or the rate of full union (52.2% vs. 56.5%, p = 0.112). For junior attendings, the use of VSP significantly increased the rate of first union within one year (76.7% vs. 62.9%, p = 0.016) but did not significantly affect the rate of full union (51.7% vs. 39.5%, p = 0.098). There were no significant differences in the rate of 30-day short-term complications (surgical site infections, delayed wound healing, seroma, hematoma, flap failure, and return to the operating room) or 1-year long term complications (osteoradionecrosis, plate fracture, and plate exposure) between any of the analyzed cohorts.
CONCLUSIONS: VSP is a powerful technology that appears to flatten the learning curve for junior surgeons performing free fibula flaps for mandibular reconstruction, contributing to union rates that are similar to those achieved by senior surgeons with substantially more clinical experience.


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