A group of plastic surgeons at Yale is using virtual 3-D planning technology to improve surgical outcomes.

“It starts with radiology,” explained Derek Steinbacher, director of Craniofacial Surgery at Yale New Haven Hospital, referencing the fact that the planning technology uses radiology in the form of three-dimensional CT scans. In the first part of the process, CT scans of patients’ skulls are obtained, and these, in conjunction with 3-D analysis tools, are used in pre-operative planning for reconstructive surgery. 3-D planning then allows the surgeon to virtually simulate the surgery using the composite images.

Other crucial components of 3-D planning include construction of cutting guides, which assist the surgeon in performing the procedure, 3-D printing of splints and other prosthetics and the ability to review the relevant anatomical landscape in advance of the procedure. 3-D planning allows surgeons to use computer-aided design and computer-aided manufacturing technology to bring industrial standards of precision to the operating room, according to Rajendra Sawh-Martinez, a chief resident in Yale Plastic and Reconstructive Surgery.

The idea is not new, but this application of it is, Steinbacher said, adding that “a lot of the 3-D platforms that we’re using now began in the architecture and automotive fields.”

Steinbacher also noted that other specialties like orthopedic surgery have begun to use 3-D planning in some of the more complex procedures. In plastic and reconstructive surgery, the technology is most commonly used in orthognathic surgery and facial reconstruction procedures.

The 3-D planning technique has been used in thousands of craniofacial reconstructive surgical cases at Yale, Steinbacher said. He went on to cite the technique’s usefulness in craniofacial operations for many different patients — a few of which included neonates born with congenitally small lower jaws. 3-D planning allowed for more precision in surgical planning, which translated to drastically improved outcomes for the patients, according to Ty Tuggle, a chief resident in Yale Plastic and Reconstructive Surgery.

“You want to talk about life-changing? These kids went from not being able to breathe to totally functional,” Tuggle said.

Steinbacher and Brian Shah, director of research at Yale Oral and Maxillofacial Surgery, both said they strongly champion this planning method, citing the new 3-D technology as crucial for their surgical preparation. Before 3-D planning, Tuggle said, plastic surgeons prepared for a case using model surgery, which used plaster molds of the patient’s jaw to help simulate the upcoming case. Model surgery was very time-consuming, labor-intensive and also inaccurate, Tuggle added.

Shah confirmed that there was previously a lot of guesswork involved He added that even with model surgery there was still a level of uncertainty in the actual execution of the procedure that could not be addressed pre-operatively. Now, with the advent of 3-D planning, the process has become much more streamlined and much less uncertain.

“You can see things on the CT scan that you would never be able to envision with the plaster models,” Shah said.

Steinbacher also heralded the technology’s potential to give surgeons numerical data on surgical outcomes, which can help improve technique and planning for future cases. Steinbacher said that the anatomical elements can now be regarded objectively, using measurements like volumes and angles.

The newfound ability to compare numerical data points from regarding the patient’s pre-operative state to the post-operative state gives surgeons more opportunities to concretely assess the efficacy of treatment.

“We use [the planning] as a frame of reference, and from it, we are able to establish and validate our goals of treatment,” Steinbacher concluded.

Further, Steinbacher said he believes that 3-D planning and related technologies, such as 3-D simulations, also help patients by giving them a better understanding of what is possible with surgery.

John Smetona, a second-year resident in Plastic and Reconstructive Surgery, affirmed the helpfulness of improved patient education, adding that it was unfair to expect patients to carry the full responsibility of understanding the highly technical details of the surgical procedures. That is where 3-D simulation helps in the dialogue between patient and doctor, according to Steinbacher.

Steinbacher said that while the method has not permeated the entire field, it is slowly gaining traction, particularly within the younger generation of surgeons.

Shah said he noticed this too, adding that residents will ask him why his hospital does not do more 3-D-guided planning.

Both surgeons cited the technology’s ease-of-use, flexibility and expanded planning functionality, as primary reasons for its utility. Additionally, Steinbacher said it is invaluable in its ability to get the surgeon thinking about the cases and visualizing the procedure before they even step into the operating room.

The Yale School of Medicine Department of Surgery has 14 surgical specialty sections.