Secondary Reconstruction of Panfacial Fractures With Virtual Reality Surgical Planning Using Both Pre and Postreconstruction Scans

Late secondary reconstruction is sometimes required in patients with suboptimal primary panfacial fracture repair. At this stage, it can be difficult to discern original facial architecture due to malunion and bony remodeling. By utilizing the original postinjury CT scan to complete fracture reduction in the virtual reality (VR) planning environment, the surgeon may attempt to recreate an "ideal" facial bony anatomy for patients. This technique was completed in 2 patients presenting with facial deformity secondary to malunited panfacial fracture. Each had a cone-beam CT (CBCT) scan taken at presentation and the initial postinjury CT scans were obtained. Fracture reductions were completed in VR to recreate the preinjury anatomy. The resulting model was overlaid with current anatomy to create surgical aids. The first patient, a 23-year-old man, presented with malunion of all bones of the midface. Cutting guides were designed for the Lefort 1 segment, left zygomaticomaxillary complex (ZMC), and naso-orbito-ethmoid (NOE) osteotomies. The second patient, a 30-year-old woman, had bilateral ZMC and subcondylar fractures, midface retrusion, and malunion of parasymphyseal fracture. A 2-stage procedure was planned, including an initial Lefort I and bilateral sagittal split osteotomy with midline wedge excision. To address malar projection, a second surgery was planned using custom MEDPOR midface implants for the NOE and zygomatic regions. Both patients were discharged home, and all surgical goals and esthetic objectives were achieved.