Type: Review article
Imaging and printing in plastic and reconstructive surgery part 1: established techniques
Michael P Chae MBBS BMedSc,1,2,3 David J Hunter-Smith MBBS MPH FRACS,1,2,3 Warren M Rozen MBBS PhD FRACS1,2,3
Department of Plastic, Reconstructive and Hand Surgery
Peninsula Clinical School
Department of Surgery
Name: Warren Rozen
Address: Monash University Plastic and Reconstructive Surgery Group (Peninsula)
Peninsula Health, Department of Surgery
2 Hastings Road
Frankston, Victoria, 3199
Email: [email protected]
Telephone: +61 3 9784 8416
Citation: Chae MP, Hunter-Smith DJ, Rozen WM. Imaging and printing in plastic and reconstructive surgery part 1: established techniques. Aust J Plast Surg. 2019;2(1):55–68. https://doi.org/10.34239/ajops.v2i1.50
Accepted for publication: 21 June 2018
Copyright © 2019. Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution Licence which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.
Section: Technology and imaging
Background: An increasing number of reconstructive surgeons are using modern imaging technologies for preoperative planning and intraoperative surgical guidance. Conventional imaging modalities such as CT and MRI are relatively affordable and widely accessible and offer powerful functionalities. In the first of a two-part series, we evaluate established three-dimensional (3D) imaging and printing techniques based on CT and MRI used in plastic and reconstructive surgery.
Method: A review of the published English literature dating from 1950 to 2017 was taken using databases such as PubMed, MEDLINE®, Web of Science and EMBASE.
Result: In plastic and reconstructive surgery, the most commonly used, free software platforms are 3D Slicer (Surgical Planning Laboratory, Boston, MA, USA) and OsiriX (Pixmeo, Geneva, Switzerland). Perforator mapping using 3D-reconstructed images from computed tomography angiography (CTA) and magnetic resonance angiography (MRA) is commonly used for preoperative planning. Three-dimensional volumetric analysis using current software techniques remains labour-intensive and reliant on operator experience. Three-dimensional printing has been investigated extensively since its introduction. As more free open-source software suites and affordable 3D printers become available, 3D printing is becoming more accessible for clinicians.
Conclusion: Numerous studies have explored the application of 3D-rendered conventional imaging modalities for perforator mapping, volumetric analysis and printing. However, there is a lack of comprehensive review of all established 3D imaging and printing techniques in a language suitable for clinicians.
Key words: image processing, 3D printing, plastic and reconstructive surgery, CTA, MRA
Performing perforator-based flap reconstruction requires careful selection of the perforator, flap design and donor site. A suitable perforator is ideally harvested from a donor site with minimal morbidity and is large enough to facilitate microsurgical anastomosis and adequately supply all portions of the flap.1 In recent times, an increasing number of plastic and reconstructive surgeons have begun using modern 3D imaging and printing technologies to aid preoperative planning, intraoperative guidance and medical education.2,3 However, there is a lack of comprehensive review of these techniques that provides a global understanding of this novel field in a language suitable for clinicians.
Currently, a plethora of imaging modalities is being used in plastic and reconstructive surgery, mainly computed tomography angiography (CTA) and magnetic resonance angiography (MRA).4–9 First reported for perforator-based flap planning in 2006,6,7 CTA is widely used in preoperative investigations by institutions around the world and is considered the gold standard due to its high accuracy and reliability.4,5,10–13 However, CTA poses the potential risk of additional radiation exposure, involves intravenous administration of iodinated contrast media and does not provide haemodynamic features such as flow velocity and direction.
Magnetic resonance angiography bypasses radiation exposure but is limited by only being able to detect vessels greater than 1 mm in diameter.14 It also has lower spatial resolution15 and poorer contrast differentiation from the surrounding soft tissue.16 As a result, MRA has a lower sensitivity (50%) for detecting abdominal wall perforators than CTA.9 Enhanced by recent advances in imaging techniques,17 contrast agents18 and increasing availability of higher field-strength scanners,19 more recent studies have reported improved sensitivity in identifying perforators (91.3–100%).8,20–24 As a result, MRA remains an investigation of choice for younger patients and for those with iodine allergy and impaired renal function.25
In this review, we evaluate the established 3D imaging and printing techniques based on CT and MRI.
We reviewed the published English literature from 1950 to 2017 from well-established databases such as PubMed, MEDLINE®, Web of Science and EMBASE. We included all studies that analyse 3D imaging and printing techniques used in surgery, especially plastic and reconstructive surgery. We used search terms such as ‘3D imaging’, ‘CTA’, ‘MRA’, ‘3D image software’, ‘volumetric analysis’, ‘3D printing’, ‘preoperative planning’, ‘intraoperative guidance’, ‘education’, ‘training’ and ‘customised implant’. We also retrieved secondary references found through bibliographical linkages.
3D imaging rendering software
Through our literature review, we identified the most commonly used 3D image rendering software suites in medical application. We identified their specifications, such as the software language on which they are based, cost, open-source capability and function, by accessing the manufacturer’s website or from publications.
3D perforator mapping
We identified that CTA and MRA are the most commonly used imaging modalities for 3D perforator mapping. Hence, we evaluated the software suites based on these modalities.
3D volumetric analysis
We focused our analysis of 3D volumetric analysis based on conventional 3D imaging techniques, CT and MRI. We systematically identified a list of software suites used to analyse 3D volumetric data from CT or MRI and examined their application in plastic and reconstructive surgery.
Studies using 3D printing for preoperative planning in plastic and reconstructive surgery were assessed using Oxford Centre for Evidence-Based Medicine levels of evidence.26 Given that the most common 3D printing application in plastic and reconstructive surgery is mandibular reconstruction with free fibular flap, we performed a focused further qualitative analysis of this application.
Results and discussion
Numerous studies have explored the application of conventional imaging modalities for 3D perforator mapping, 3D volumetric analysis and 3D printing.
3D image rendering
Proprietary software provided by manufacturers of CT and MRI scanners generally offers only two-dimensional image-viewing capabilities. As a result, numerous free, open-source software platforms have been developed that are capable of 3D image rendering. They are built on robust, but limited, open-source software libraries that provide the basic architecture. In plastic and reconstructive surgery, the most commonly used free software platforms are 3D Slicer (Surgical Planning Laboratory, Boston, MA, USA) and OsiriX (Pixmeo, Geneva, Switzerland) (see Table 1).
|3D Slicer||Surgical Planning Laboratory (Boston, MA, USA)||C++||Yes||Yes||Built on ITK and VTK|
|Python||Easy-to-use graphical user interface|
|Creates 3D images of regions of interest suitable for 3D printing|
|OsiriX||Pixmeo (Geneva, Switzerland)||Objective-C||Yes||No||Built on ITK and VTK|
|Enables both viewing and 3D rendering of anatomical structures|
|Easy-to-use graphical user interface|
|Has both 3D rendering techniques: volume-rendered technique and maximum intensity projection|
3D Slicer27 is a well-supported, open-source platform built on Insight ToolKit (ITK) and Visualisation ToolKit (VTK) using C++ and Python.2 Developed to segment brain tumours from MRI scans28 3D Slicer is used in a variety of medical applications ranging from lung cancer diagnosis29 to cancer imaging.30 This software is adept at generating volumetric images for 3D printing through thresholding and segmentation techniques (see below).
The OsiriX31 image-viewing software platform is built on ITK and VTK, for Macintosh computers only. It has an intuitive graphical user interface and fast processing speed make it popular with clinicians worldwide.31 OsiriX enables viewing of multidimensional data such as positron emission tomography (PET)-CT32 and cardiac-CT as well as standard tomographic scans (CT and MRI).33 It is suitable for viewing 3D and 4D datasets but limited to 3D anatomical models of large organs such as long bones and the heart.
3D perforator mapping
In perforator based, free flap reconstruction, plastic surgeons commonly rely on CTA- or MRA-based 3D reconstructed images of the relevant perforators for preoperative planning (see Figure 1).
Figure 1. CTA-based 3D perforator mapping in DIEP flap planning performed using OsiriX software
(A) MIP reconstruction demonstrating the intramuscular and subcutaneous course of each perforator and (B) VRT reconstruction demonstrating the location of the perforators (blue arrows) as they emerge from the rectus sheath in reference to the umbilicus (marked). CTA: computed tomographic angiography 3D: three-dimensional DIEP: deep inferior epigastric artery perforator MIP: maximum intensity projection VRT: volume-rendered technique DIEA: deep inferior epigastric artery.
Computed tomography angiography is the most commonly used imaging modality for 3D perforator mapping, using maximum intensity projection (MIP) and volume-rendered technique (VRT) 3D software reconstruction techniques. Compared with Siemens Syngo InSpace 4D (Siemens, Erlangen, Germany) and VoNaviX (IVS Technology, Chemnitz, Germany), which are expensive, and virSSPA (University Hospitals Virgen del Rocio, Sevilla, Spain), which is not available outside the original institution, OsiriX software platform is free and has been demonstrated to be as accurate.
Modern magnetic resonance technology can provide superior 3D reconstructed images. However, they are expensive, time-consuming and relatively difficult to perform. Similar to CTA, free OsiriX software can be used for 3D perforator mapping from MRA. Recently, investigators have developed a semi-automated plugin tool for analysing MRA images using OsiriX, However, it remains to be validated in a large cohort.
3D volumetric analysis
Accurate assessment of tissue volume is an important aspect of preoperative planning in plastic surgery.34–38 Particularly in breast reconstructive surgery, volumetric analysis is paramount for achieving symmetrisation and a satisfactory outcome.39–44 However, an accurate, reliable and convenient method of objective breast volumetric analysis has remained elusive (see Figure 2 and Table 2).45
Figure 2. MRI-based 3D volumetric analysis in planning breast reconstructive surgery demonstrating 611 mL on the right breast and 635 mL on the left breast, performed using OsiriX software (Pixmeo).
|OsiriX||Pixmeo, Geneva, Switzerland||Yes||No||Breast|
|Aquarius Workstation||TeraRecon Inc., San Mateo, CA, USA||No||No||Breast, DIEP flap|
|Mimics||Materialise NV, Leuven, Belgium||No||No||DIEP flap|
|Leonardo Workstation||Siemens AG, Munich, Germany||No||No||DIEP flap|
|ImageJ||NIH, Rockville, MD, USA||Yes||No||Orbital volume|
|Vevo LAB||Fujifilm ViewSonics, Toronto, Canada||No||No||Autologous fat graft in mice|
|SkyScan CTan||Bruker, Kontich, Belgium||No||No||Limb lymphoedema in mice|
|OsiriX||Pixmeo, Geneva, Switzerland||Yes||No||Breast, Breast implant,
limb lymphoedema in mice
|Volume Viewer Plus||GE Healthcare, Waukesha, WI, USA||No||No||Breast|
|BrainLAB||BrainLAB AG, Feldkirchen, Germany||No||No||Breast, Breast implant|
|Medis Suite MR||Medis Medical Imaging Systems BV, Leiden,
|No||No||Breast, Breast implant|
|AW Server||GE Healthcare, Waukesha, WI, USA||No||No||Breast glandular tissue|
|Dextroscope||Volume Interactions, Singapore||No||No||Malar fat pad|
|ImageJ||National Institutes of Health, Rockville, MD, USA||Yes||No||Breast|
DIEP: deep inferior epigastric artery perforator. Source: Eder et al,39 Rha et al,41 Rosson et al,43 Herold et al,44 Lee et al,46 Chae et al,51 Rha et al,52 Blackshear et al,131 and Corey et al135
Calculating the flap volume from CTA and comparing it with the intraoperative flap weight, Eder et al reported high correlation between the two measurements (r=0.998, p <0.001) demonstrating the high prediction accuracy of CTA (0.29%; –8.77 to 5.67%).39
In order to further improve its accuracy, Rosson et al placed fiducial markers on the surgical incision line before the CTA and achieved accuracy of up to 99.7 per cent (91–109%).43
Lee et al calculated a ratio using the volume of the breast and the potential deep inferior epigastric artery perforator (DIEP) flap from CTA and created a treatment algorithm.46 If more than 50 per cent of the harvested flap is required for reconstruction, surgeons can make modifications to the flap design by increasing its height, capturing more adipose tissue by bevelling superiorly from the flap’s upper margin, like Ramakrishnan’s extended DIEP technique,47 and incorporating multiple perforators if available. If more than 75 per cent of the flap is required, venous augmentation is performed with contralateral superficial inferior epigastric vein. Using this algorithm in 109 consecutive patients, the authors noted a significant reduction in perfusion-related complications (5.6 vs 22.9%, p=0.006) and fat necrosis (5.6 vs 19.1%, p=0.03).
In comparison to CT, MRI has superior soft-tissue resolution and is thus more accurate at measuring breast volumes (r=0.928 vs 0.782, p=0.001)48 and has a mean measurement deviation of only 4.3 per cent.49 Furthermore, Rha et al show that MRI-derived breast volume is more accurate than the traditional volumetric method using a plaster cast (r2=0.945 vs 0.625).
Using the manufacturer’s specifications as gold standard, Herold et al measured the volume of breast implants using MRI in patients with bilateral augmentation mammaplasty.44 Furthermore, they compared the accuracy of three commonly available 3D image processing software platforms: OsiriX, BrainLAB (BrainLAB AG, Feldkirchen, Germany) and Medis Suite MR (Medis Medical Imaging Systems BV, Leiden, The Netherlands). BrainLAB had the lowest mean deviation of 2.2 ± 1.7 per cent, followed by OsiriX at 2.8 ± 3.0 per cent and Medis Suite MR at 3.1 ± 3.0 per cent. However, all software platforms correlated highly accurately with the reference overall (r=0.99). Interestingly, software analysis is fastest using OsiriX at 30 seconds per implant, followed by BrainLAB and Medis Suite MR at 5 minutes.
To date, most software techniques remain manual, that is labour-intensive and reliant on operator experience, while validated evidence of commercially available automatic segmentation tool is scarce.50,51 Interestingly, Rha et al used ImageJ, a free NIH-developed image processing program, to successfully perform volumetric analysis of the orbit and breast from CT and MRI, respectively.52 However, ImageJ has yet to be investigated in clinical application
In contrast to medical imaging modalities that are limited by being displayed on a 2D surface, such as a computer screen, a 3D-printed biomodel can additionally provide haptic feedback.2,53–56 Three-dimensional printing, also known as rapid prototyping or additive manufacturing, describes a process by which a product derived from computer-aided design (CAD) is built in a layer-by-layer manner.57–59 The main advantages of 3D printing are the ability to customise, cost-efficiency and convenience.60,61 Since its introduction, the use of 3D printing in surgery has been extensively investigated.
In clinical application, two types of software platforms are required for 3D printing: 3D modelling software that can convert standard Digital Imaging and Communications in Medicine (DICOM) files from CTA/MRA into a CAD file; and 3D slicing software that divides the CAD file into thin data slices suitable for printing.62 A range of modelling software is available but only the following are user-friendly and commonly reported: 3D Slicer,51,63 OsiriX64 and Mimics (Materialise NV, Leuven, Belgium).65 Three-dimensional slicing software usually accompanies 3D printers at no additional cost and has a simple user interface such as Cube software (3D Systems, Rock Hill, SC, USA), MakerBot Desktop (MakerBot Industries, New York, NY, USA) or Cura (Ultimaker BV, Geldermalsen, The Netherlands).
In clinical application, a host of 3D printer types have been used including fused filament fabrication (FFF), selective laser sintering (SLS), stereolithography (SLA), binder jetting and multijet modelling (MJM).2 Fused filament fabrication is the most common and most affordable 3D desktop printing technology available.66–68 In an FFF 3D printer, a melted filament of thermoplastic material is extruded from a nozzle moving in the x–y plane and solidifies upon deposition on a build plate.69 More recently, 3D metal printing using SLS has gained popularity in creating sterilisable surgical guides70,71 and customised dental implants.72
Encouraged by its potential, surgeons from a wide range of specialities have applied 3D printing to their practice such as neurosurgery,73–80 cranio-maxillofacial surgery,81–88 cardiothoracic surgery,89,90 orthopaedic surgery,91,92 transplantation,93–95 ear, nose and throat surgery96,97 and breast cancer surgery.98 Similarly, in reconstructive plastic surgery, 3D printing appears most useful for preoperative planning, intraoperative guidance, medical education and creating custom implants. 3D-printed bespoke implants overlap significantly with 3D bioprinting99–101 and are beyond the scope of this article.
Three-dimensional printing has been most commonly used in plastic and reconstructive surgery for preoperative planning (see Table 3).
|Clinical application||3D-printed model||Imaging||3D modelling software||3D printer|
|DIEP||Asymmetrical breast||CTA||Osirix (Pixmeo, Geneva, Switzerland)||Cube 2 (3D Systems, Rock Hill, SC, USA)|
|DIEP||Breast||CTA||AYRA (Virgen del Rocio University Hospital, Sevilla, Spain)||FFF|
|Case series of 35||IMA perforator||CT||Mimics (Materialise NV, Leuven, Belgium)||ProJet x60 (3D Systems, Rock Hill, SC, USA)|
|DIEP||DIEP flap||CTA||Mimics (Materialise NV, Leuven, Belgium)||Objet500 Connex1 (Stratasys, Eden Prairie, MN, USA)|
|Lower limb soft-tissue defect||Reverse model of the defect||CTA||Osirix (Pixmeo, Geneva, Switzerland)||Cube 2 (3D Systems, Rock Hill, SC, USA)|
|Sacral soft-tissue defect||Sacral defect||CT/MRI||Osirix (Pixmeo, Geneva, Switzerland)||Cube 2 (3D Systems, Rock Hill, SC, USA)|
|Case series of five|
|Hemi-mandibulectomy||Mandible and giant invasive SCC||CTA||3D Slicer (Surgical Planning Laboratory, Boston, MA, USA)||MakerBot Z18 (MakerBot Industries, New York, NY, USA)|
|Bony defect of the wrist||Bony defect||CT||MeshMixer (Autodesk, San Rafael, CA, USA)||Micro 3D Printer (M3D, Fulton, MD, USA)|
|Case series of three|
|4D printing of thumb movements||Hand||4D CT||Osirix (Pixmeo, Geneva, Switzerland)||Cube 2 (3D Systems, Rock Hill, SC, USA)|
|Nasal cartilaginous defect||Nasal alar cartilage||MRI||GOM Inspect (GOM GmbH, Braunschweigh, Germany)||ZPrinter 250 (3D Systems, Rock Hill, SC, USA)|
|Augmentative rhinoplasty||Individualised nasal implant||CT||Rhinoceros (McNeel, Seattle, WA, USA)||Cubicon Single (Hyvision System, Seongnam, South Korea|
|Case series of seven|
CTA: computed tomographic angiography DIEP: deep inferior epigastric artery perforator SCC: squamous cell carcinoma FFF: fused filament fabrication IMA: internal mammary artery.
Source: Chae et al,5,63,136 Garcia-Tutor et al,64 Gillis et al,102 Mehta et al,103 Suarez-Mejias et al,104 Cabalag et al,105 Taylor et al,106 Visscher et al,107Choi et al108
Autologous breast reconstruction
In 2014, Gillis and Morris reported the first case of a 3D-printed internal mammary artery (IMA) and its perforators, a common recipient site in free flap breast reconstruction.102 Similarly, Mehta et al 3D-printed a multi-colour, multi-material model of a deep inferior epigastric artery (DIEA) and its perforators.103 Despite the benefits, both studies revealed the high cost of 3D printing (US$400–US$1200 per model), mainly due to having to outsource the manufacturing. In addition, outsourcing introduces delays of up to six to eight weeks that may not be appropriate in some clinical settings. As a result, Suarez-Mejias et al developed their own 3D modelling software called AYRA (Virgen del Rocio University Hospital, Sevilla, Spain).104 More recently, Chae et al described an affordable and convenient technique of 3D printing using free software platforms and desktop 3D printers (see Figure 3).51
Figure 3. 3D-printed biomodel of breasts in planning reconstruction using Cube 2 printer (3D Systems, Rock Hill, SC, USA). Reproduced with permission from Chae et al51
In a case of lower limb reconstruction, Chae et al 3D-printed a model of the soft-tissue defect that aided in flap design.63 Similarly, Garcia-Tutor et al used 3D-printed models of large sacral defects to perform qualitative and quantitative volumetric assessment.64 Cabalag et al fabricated a model of a giant squamous cell carcinoma that was useful for planning hemi-mandibulectomy and determining the length of the free fibular flap required.105
Taylor and Lorio 3D-printed, in-house, a negative mould of a scaphoid/lunate defect from avascular necrosis from which a silicone model was created, sterilised and used intraoperatively for flap planning.106 In an interesting application, Chae et al described their technique of four-dimensional (4D) printing whereby multiple models of the thumb and wrist bones were 3D printed from 4D CT scans to demonstrate their dynamic relationship.
Three-dimensional assessment of nasal cartilaginous defect can be useful for planning reconstruction. Visscher et al demonstrated that 3D printing alar cartilages using MRI showed a mean error of 2.5 mm.107 Interestingly, most of the difference was found in 3D printing the medial crus but the lateral crus remained highly accurate, probably due to its more linear shape. Recently, Choi et al 3D-printed a patient-specific negative mould from CT to create silicone nasal implants for augmentative rhinoplasty using in-house software108 and demonstrated a mean accuracy of 0.07 mm (0.17%) with no complications.
Use of 3D-printed fibular osteotomy guides for mandibular reconstruction has been studied extensively (see Table 4).66,109–123 Investigators have demonstrated their accuracy of up to 0.1–0.4 mm.66,110–112,117 Moreover, they can significantly reduce flap ischaemia time (120 minutes vs 170 minutes, p=0.004)114 and total operating time (8.8 hours vs 10.5 hours, p=0.0006).117
|Year||Patients||Source of 3D printing||Imaging||3D rendering software||3D printers|
|2017||18||In-house||CT||AYRA (Virgen del Rocio University Hospital, Sevilla, Spain)||Objet30 Pro (Stratasys, Eden Prairie, MN, USA)|
|Osirix (Pixmeo, Geneva, Switzerland)||Zortrax M200 (Zortrax, Olsztyn, Poland)|
|3D Slicer (Surgical Planning Laboratory, Boston, MA, USA)|
|MeshMixer (Autodesk, San Rafael, CA, USA)|
|Blender (Blender Foundation, Amsterdam, The Netherlands)|
|2017||3||Outsourced||CT||Osirix (Pixmeo, Geneva, Switzerland)|
|MeshLab (ISTI, Pisa, Italy)|
|Netfabb (Autodesk, San Rafael, CA, USA)|
|Blender (Blender Foundation, Amsterdam, The Netherlands)||Formiga P 100 (EOS, Munich, Germany)|
|2017||7||Outsourced||CT||E3D Online (E3D Online, Oxfordshire, UK)||ProJet 3510 HD (3D Systems, Rock Hill, SC, USA)|
|Amira (FEI Company, Hillsboro, OR, USA)|
|2016||1||In-house||CT||Blender (Blender Foundation, Amsterdam, The Netherlands)||PolyJet (Stratasys, Eden Prairie, MN, USA)|
|2015||1||Outsourced||CT||SurgiCase CMF (Materialise NV, Leuven, Belgium)||SLM|
|2013||68||Outsourced||CT||ProPlan CMF (Dupuy Synthes CMF, West Chester, PA, USA)||SLA|
|2013||48||Outsourced||CT||VoXim (IVS Technology, Chemnitz, Germany)||SLA|
|2013||10||Outsourced||CT||ProPlan CMF (Dupuy Synthes CMF, West Chester, PA, USA)||SLA|
|2013||38||Outsourced||CT||SurgiCase CMF (Materialise NV, Leuven, Belgium)||SLA|
|2012||1||Outsourced||CT||SurgiCase CMF (Materialise NV, Leuven, Belgium)|
|Rhinoceros (McNeel, Seattle, WA, USA)||M 270 (EOS, Munich, Germany)|
|2012||1||In-house||CTA||AYRA (Virgen del Rocio University Hospital, Sevilla, Spain)||FFF|
|2012||9||In-house||CT||Mimics (Materialise NV, Leuven, Belgium)||SLA 3500 (3D Systems, Rock Hill, SC, USA)|
|2012||15||Outsourced||CT||Magics (Materialise NV, Leuven, Belgium)||SLA|
|2009||3||Outsourced||CT||Extended Brilliance Workspace (Philips Healthcare)||Objet Eden 500V (Stratasys, Eden Prairie, MN, USA)|
|2009||1||Outsourced||CT||SurgiCase CMF (Materialise NV, Leuven, Belgium)||SLS nylon|
Educating junior surgical trainees and medical students about 3D pathological defects such as cleft lip and palate without hands-on interaction and demonstration is notoriously difficult. As the supply of cadavers for medical education continues to dwindle due to rising maintenance costs124 and concerns regarding occupational health and safety,125 the use of 3D-printed biomodels has become popular.126,127 Zheng et al have used 3D-printed negative moulds to fabricate soft silicone models of cleft lip and palate on which students directly perform cheiloplasty.128 Subsequently, in a randomised clinical trial of 67 medical students, AlAli et al demonstrated that the knowledge gained using 3D-printed models of cleft lip and palate was significantly higher than when using standard slide presentations (44.65% vs 32.16%, p=0.038).129 Similarly, clinicians have 3D printed negative moulds of paediatric microtia for practical demonstration.130
Many studies have explored the application of 3D-rendered conventional imaging modalities for 3D perforator mapping, 3D volumetric analysis and 3D printing. There are numerous free, open-source software platforms that are capable of 3D image rendering, such as 3D Slicer and OsiriX. For perforator mapping, most plastic surgeons rely on CTA- or MRA-based 3D reconstructed images. Current 3D volumetric analysis technologies remain labour-intensive and are yet to be automatised. 3D printing has been most commonly used in plastic and reconstructive surgery for preoperative planning in mandibular reconstruction with a free fibular flap. The majority of these studies have a lower level of evidence, consisting of case series and reports. Furthermore, there is a lack of comprehensive review of all established 3D imaging and printing techniques in a language suitable for clinicians.
The authors have no financial or commercial conflicts of interest to disclose.
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