Discussion: Computer-Assisted versus Conventional Freehand Mandibular Reconstruction with Fibula Free Flap: A Systematic Review and Meta-Analysis.

www.PRSJournal.com 1429 I this article, the authors report the results of a systematic literature review and meta-analysis comparing computer-assisted mandibular reconstruction to conventional freehand mandibular reconstruction using free fibula flaps.1 This is one of the first studies to compare these two different techniques. After reviewing 647 articles and applying exclusion criteria, 12 articles were selected. Many different variables were studied, including ischemic time, operative time, patient length of stay, accuracy, and cost. In conducting these results, accuracy was the most difficult variable to compare. There was such a diversity of measurements used in the studies that a meta-analysis could not be conducted. However, computer-assisted mandibular reconstruction did appear to have superior or equivalent accuracy in most of the studies, when parameters such as condylar and gonial shift were compared to computer-assisted mandibular reconstruction. In addition, computer-assisted mandibular reconstruction showed reduced ischemic time, operative time, and length of stay. These findings are not surprising given the complexity of free fibular reconstruction of the mandible. With conventional freehand mandibular reconstruction, many decisions are made intraoperatively that affect subsequent aspects of the operation. The amount of resection determines the amount of fibula that must be harvested, and this in turn must be secured to the contoured reconstruction plate. Bending the plates is very complex and time consuming, and there is little tolerance for inaccuracies, as remaining teeth need to be placed in occlusion. An additional element of complexity is cutting the fibula to the contours of the reconstruction plate, maintaining bone-to-bone contact at each cut. With computer-assisted mandibular reconstruction, almost all of these elements can be planned preoperatively. The physician spends time before surgery with technicians to plan the resection and the reconstruction, including the shape of the plate and the appropriate cutting of the free fibular flap. At the time of surgery, the surgeon is typically equipped with a customized prebent plate and cutting guides for the fibula. One can see that this should certainly diminish time spent in the operating room and inaccuracies resulting from intraoperative decision-making. That having been said, the comparisons around cost are much more difficult to discern. One of the studies found an extra cost with computer-assisted mandibular reconstruction of $1231.50 with a prebent plate and over $3000.00 with a patientspecific surgical plate. The differential would be higher, but with the computer-assisted mandibular reconstruction, the time savings from the shorter procedure reduce the cost of the operating room time. However, costs are variable from country to country and the coverage of these costs by insurers is highly variable. Further complicating the issue with computer-assisted mandibular reconstruction is quantifying the cost of the surgeon’s time preoperatively in the planning sessions. These economic issues cannot be overstated. As the margins in health care continue to go down, cost will be a significant factor in institutional purchasing patterns around technology such as this.