Computer-Assisted Surgery Increases Efficiency of Mandibular Reconstruction with Fibula Free Flap.

Abstract

Sir: We thank Dr. Ince and colleagues for their consideration regarding “Computer-Assisted versus Conventional Freehand Mandibular Reconstruction with Fibula Free Flap: A Systematic Review and Meta-Analysis.”1 We agree that patients with different mandibular diseases would affect surgical outcomes, including accuracy, efficiency, and reconstruction outcomes. We attempted a meta-analysis of individual patient data but failed. One consideration is that the limited number of cases in each single disease (Table 1) would compromise the reliability of the analysis. In addition, this may also limit the interpretation of data in the clinical setting, because the surgical procedures of mandibular reconstruction are largely similar despite different diseases. In addition, apart from different disease categories, surgical outcomes are closely related to different types of mandibular defects.2 To address the bias, we recommend a prospective, randomized, controlled clinical trial to control confounding factors in different groups, which was discussed in our original article.1 In any case, our article summarizes the available data and concludes that computer-assisted surgery can improve the efficiency of mandibular reconstruction, but the quality of included studies should be kept in mind and the conclusions cannot be overinterpreted. Table 1. - Diseases, Surgeon Team, and Reported Outcomes in Included Studies Authors and Year Diseases* Single-Surgeon Team Reconstructive Time Ischemic Time Total Operative Time Hospital Stay CAMR CFMR Ciocca et al., 2015 M (3), BL (2) M (4), BL (1) Unknown Gil et al., 2015 M (4), BL (2), OM (4) M (9), OM (1) Yes ✓ ✓ ✓ Zweifel et al., 2015 M (8), OM (1) M (11) Yes ✓ Weitz et al., 2016 M (19), BL (2), OM (29) Not ✓ Zhang et al., 2016 BL (8) BL (14) Yes ✓ Tarsitano et al., 2016 M (14), BL (6) M (15), BL (5) Yes ✓ ✓ ✓ Wang et al., 2016 M (6), BL (8), OM (7) M (18), BL (7), OM (10) Yes ✓ ✓ Culie et al., 2016 M (16), other (2) M (7), OM (2), other (2) Not* ✓ ✓ ✓ Maesschalck et al., 2017 M (6), OM (1) M (6), OM (5) Not Ritschl et al., 2017 M (5), BL (1), OM (10) M (4), BL (2), OM (8) Not‡ ✓ ✓ Bao et al., 2017 M (4), BL (22) M (1), BL (8) Yes ✓ ✓ Bouchet et al., 2018 M (12) M (13) Yes ✓ ✓ ✓ CAMR, computer-assisted mandibular reconstruction; CFMR, conventional freehand mandibular reconstruction; M, malignancy; BL, benign lesions; OM, osteomyelitis and osteonecrosis.*Diseases are categorized into malignancy, benign lesions, osteomyelitis and osteonecrosis, and other.†Operations were performed by three senior surgeons with more than 10 years’ experience.‡Computer-assisted mandibular reconstructions were being performed by younger consultants with less experience. In terms of the pooled data of reconstructive time, ischemic time, and total operative time, we have conducted our meta-analysis based on standard protocols, using the fixed-effect models to reflect statistical heterogeneity.3 We agree with Dr. Ince and colleagues that these data should be interpreted carefully because of the severe heterogeneity of ischemic time, reconstructive time, and total operative time. From the clinical perspective, most of the studies we included were conducted by the same surgical team, which helped reduce heterogeneity to some extent (Table 1). However, the operation time is affected by many confounding factors and should be properly managed in future studies. It is also important to note that computer-assisted surgery can compensate for the lack of experience in junior surgeons, which highlights the prospect of computer-assisted surgery.4,5 In conclusion, according to the current evidence, computer-assisted surgery can increase the efficiency of mandibular reconstruction with fibula free flap. The limitations inherent in our meta-analysis call for more well-designed studies in this field in the future. ACKNOWLEDGMENTS This study was supported by the Health and Medical Research Fund (project no. 05161626), Food and Health Bureau, Hong Kong. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.