Fig. 3

Bilateral mandibulectomy with fibular free flap reconstruction using 3D printing: example of ‘Complex’ 3D printing. A 50-year-old man with aggressive squamous cell carcinoma centered in the mandibular region was evaluated for surgical intervention. 3D printed parts of the patient anatomy were created from Computer Aided Design (CAD), based on the segmented CT data for digital planning of the procedure. The final anatomic representations for both the mandible and fibula (used for the graft) were created to fit with a custom 3D printed titanium plate. That titanium plate was fabricated by industry, for this patient by KLS Martin (Jacksonville, FL). All other parts of the clinical service were performed in the Health Care Facility (HCF). The digital surgical plan performed in the Health Care Facility (HCF) conceptualized the fixation of the osteotomized fibula to the remaining symphysis. This requires the placement of cutting planes in the region of interest providing a 1-to-2-cm margin of normal bone. The HCF engineer then designed the cutting guides to fit the underlying anatomy with screw holes to secure to bone and slots made for each size oscillating saw blade. For the fibular free flap vascular graft, in the HCF, the length and shape of segments of the fibula required for reconstruction are translated directly from the planned mandibular reconstruction and are marked in color. The planning also uses CT angiography to assure that the leg vessels are patient, and to identify their position. Adequate perforators are also assessed to optimize flap survival. After the segments from the mandible are transferred to the fibula, the engineer created patient specific osteotomy guides similar to the mandible by subtracting the underlying fibular geometry to assure a perfect fit. Labels were digitally added to ensure proper orientation when the fibula is transferred into the defect. In addition, a 3D printed sterilizable model was autoclaved to use as reference on the back table in the operating room (not shown). The fibula was harvested leaving the blood supply connected to the parent artery while the sterilized osteotomy guides are attached with fixation screws. Osteotomy was performed while the vascular pedicle was attached; that is, the clock on the ischemia time had not started until the flap was finally harvested. Because harvesting the FVFG depends on the peroneal vessels, the periosteum was kept intact to ensure vascular supply to all fragments. Submental incision was placed and the mandible is exposed (not shown). A the HCF 3D printed mandibular cutting guide was secured in place with screws. The surgeon then performed the osteotomies in the preplanned trajectories. Resection of the osteoradionecrotic segments of the mandible was performed. 3D printed, sterilizable fixation trays (not shown) were designed in the HCF to secure the mandibular section into place and to allow the custom titanium plate to be affixed in the proper location efficiently, limiting ischemia time. Posts for the future mandibular prosthesis were placed at this time; B the titanium plate and fibular flap were then transferred into the operative defect in one piece further limiting ischemia time and replicating the surgical plan. Finally, using the standard microsurgical technique, the artery and vein were then anastomosed with lingual-facial vessels. (Published with kind permission of © Mayo Clinic. All Rights Reserved). Reproduced from Rybicki, F.J., Morris, J.M., Grant, G.T. (eds) 3D Printing at Hospitals and Medical Centers: A Practical Guide for Medical Professionals. Springer, Cham. Switzerland. DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1007/978-3-031-42851-7