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Application of Advanced Technologies in Facial Cosmetic Surgery: History, Denition…
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Fig. 8 Design and fabrication of an auricular prosthesis utilizing CAD/CAM.The unique scheme
called S3PP was utilized to make a substructure for the auricle epithesis (left) and inserted epithesis (right) [8]
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Generally, the security, hands-free property, noninvasiveness, exactness (extending from 0.9 to 2mm in the normal range errors of 1.4mm), decreased procedure
time, diminished complexity, upgrading material and visible data, enhanced students’ conception of anatomical structures, and surgical condence can be appraised
as the points of interest of VR/AR innovation. Some drawbacks of these methods
include impedances with the operation eld, the largeness of a few gadgets, and
motion boundaries in limited elds, including the mouth [13].
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Fig. 9 Reconstruction of the nasal tip using a nasal prosthesis device in a female unable to undertake reconstructive surgery [9]
S. O. Keyhan et al.
Fig. 10 Dynamic navigation system in zygomatic implant placement (Ramezanzade S et al.
Dynamic-assisted navigational system in zygomatic implant surgery: a qualitative and quantitative
systematic review of current clinical and cadaver research. Journal of Oral and Maxillofacial
Surgery. 2021 Apr 1;79(4):799–812) [12]
Application of Advanced Technologies in Facial Cosmetic Surgery: History, Denition…
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Fig. 11 3D facial scanning of patient and outcome prediction following orthognathic surgery
Fig. 12 The mixed reality technologies spectrum [13]
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S. O. Keyhan et al.
7 Virtual Surgical Planning (VSP) andComputer-Aided
Design/Computer-Aided Manufacturing (CAD/CAM)
With the use of three-dimensional (3D) imaging software, the focus has been
switched from the surgeon’s subjective analysis to a more facile linkage of preoperative treatment plan and intraoperative performance that improves outcomes.
Regarding orthognathic surgery, virtual surgical planning (VSP) eliminates the
laboratory process which is essential in conventional model surgery. By eliminating
the laboratory steps leading to mistakes, it is anticipated that VSP will warrant the
denite outcomes [16, 17] (Figs.13, 14, and 15).
Fig. 13 The “beauty arch” analysis for malar augmentation [9, 18]. A three-dimensional com-
puted tomography of the face. The raw data was entered into the KAVEH software (KAVEH
Package, Tehran, Iran) for the virtual zygomatic osteotomy. Zygomatic sandwich osteotomy was
done on the virtual 3D model available in the KAVEH software. Two surgical templates for bilateral zygoma were made using the rapid prototyping technology (SLA technology-RUNA CO.,
Tehran, Iran). The left and right template are xed to the respective zygomatic areas and osteotomy
was done using template edges [18]. Preoperative and postoperative lateral view photographs of a
24-year-old female with midface deciency who underwent malar augmentation by zygomatic
sandwich osteotomy using a 3D printed surgical splint. This method could prevent the complications of malar augmentation procedure, including nerve injury, orbital oor fracture, and unwanted
fractures of maxillary sinus’ lateral walls [18]
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Fig. 13 (continued)
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S. O. Keyhan et al.
Fig. 14 Virtual model surgery; (a, b) preop occlusion, (c, d) intermediate occlusion, (e, f) nal
occlusion
The benets of applications of the virtual surgical planning in craniomaxillofacial procedures can be summarized as follows:
1. Exact and comprehensive diagnosis
2. Preoperative procedure simulation
3. Provision of the data to design templates or personalized pre-shaped implants
4. Prediction of operation outcomes and evaluation of the feasibility of the opera-
tion (Figs.16, 17, and 18)
7.1 The Steps ofVirtual Surgery Planning
1. Data acquisition (CT, DVT, MRI)
2. Scanning Digital Imaging and Communications in Medicine (DICOM) les for
3D modeling and diagnostic and production purposes
ab
Application of Advanced Technologies in Facial Cosmetic Surgery: History, Denition…
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c
d
e
Fig. 15 Virtual treatment plan designing in surgery-rst bimaxillary orthognathic surgery patient.
(a) Intermediate occlusion after correction of maxillary position, (b) the placement of the mandible
into the proper occlusion, (c, d, e) evaluation of right and left proximal segment position and the
need for genioplasty
Fig. 16 The rapid metal
prototype orbital oor
implant [7]
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Fig. 17 (a) Pre-bended reconstruction plate before mandibular marginal resection (b) consider
precise anatomic alignment of the pre-bended plate and mandibular border [7]
S. O. Keyhan et al.
Fig. 18 Preoperative and postoperative photographs of a patient with appropriate occlusion suffering from mandibular deciency, lip incompetence due to chin hypoplasia, and excessive soft
tissue at the chin. The operative plan includes an advancement genioplasty, bilateral preprinted
mandibular angle implant, minimally invasive rhinoplasty, and lip ller injection
Application of Advanced Technologies in Facial Cosmetic Surgery: History, Denition…
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3. Virtual segmentation, osteotomy, or reduction with or without mirror imag-
ing methods
4. Creation of templates, implants, rapid prototyping, and 3D stereolithographic
models (STL models)
5. Entering virtual planning data into a navigation system for the surgeon or robotic
guidance system
Despite the widespread use of VSP in dentistry and its signicant preponderance
over older methods, VSP has drawbacks such as high cost, learning curve, and time
wasting in situations that limit its use regularly. Generally, the CAD system’s essential features for craniomaxillofacial surgical procedures encompass the ability for
medical image segmentation, fusion, and volume rendering. The graph cut algorithm can generate high-quality volume and accurately segmented soft-tissue
tumors. Tumors extracted from CT data can be viewed in 3D and their volume can
be measured with 99.5% agreement with the actual tumor volume.
Another characteristic of CAD is CT/MRI image fusion and creation of new
images with more accurate details. It can also fuse images captured with other
imaging devices, such as merging CT data with the dentition’s 3D laser scan image
data [19].
Rapid prototyping 3D models can create physical objects directly from data
sources from CAD (computer-aided design). RP allows you to design and manufacture models faster than traditional manual prototyping techniques. This technique is
based on distinct and cumulative forming theory that manufactures material layer
by layer. Based on the CT scan data, a mock-up is fabricated at a 1:1 scale.
3D model production can be summarized as follows:
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1. A collection of high-quality scan data
2. Three-dimensional image conguration
3. Mathematical surface modeling of anatomical surfaces
4. Data composition and rapid prototype model fabrication
The RP as a method for producing mock-up is currently employed in many medical specialties and consists of stereolithography, selective laser sintering, fused
deposition, etc. The accuracy of stereolithography is mainly acceptable for medical
RP, and it is the most commonly used in craniomaxillofacial reconstructive procedures [16].
8 Endoscopically Assisted Surgery
Endoscopy is a minimally invasive approach in which physicians can reach and
manipulate inaccessible target organs through a keyhole. The endoscope includes a
lens, a light source, and a delivery shaft. Several types of endoscopes are available
regarding the length of the shaft and the quality and angulation of the lens; 4-mmand 2.7-mm-diameter endoscopes with 0, 30, and 45° angulation of the lens are the
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most common ones used in the orbital complex and cosmetic surgery. Endoscopic
eyebrow lift and upper face lift are among the most popular endoscopic cosmetic
procedures. Although the complications of conventional trans-coronal lift will be
diminished, under-correction of the lift was one of the initial endoscopic lift limitations. With acceptable results, an endoscopic approach to maxillofacial trauma has
been reported in treating orbital and zygomatic arch fractures, frontal sinus fractures, and mandibular sub-condylar fractures. Endoscopic reduction is indicated by
the fracture’s dimension, extension, site, and the surgeon’s experience. Endoscopeassisted surgery of orbital oor fractures could decrease the complication related to
the lower eyelid conventional surgery including malpositioning and enophthalmos.
The overall concept around this procedure is less invasive surgery with limited incisions, reduced patient morbidity (pain, hospitalization, infection), and quicker
patient recovery. The steep learning curve, market price, regular machine updates,
and technology reliance could be considered disadvantages [20, 21].
The nine key points are suggested to create the learning curve smoother in shifting from conventional to endoscopic operation (Table1).
The image quality and reliability of endoscopy continue to improve with recent
advances. The future of endoscopic surgery, 3D imaging, and navigation system is
exciting [22].
Table 1 Nine key points are recommended for the more tranquil learning curve
1. Concerning the endoscopic operation in different facial units, summarize (books and
articles) and reappraise (cadaveric dissection) the facial anatomy
2. During the conventional operation, use the endoscope to inspect the facial units—for
example, nasal endoscopy and external DCR
3. Take a 3- to 6-month course for different endoscopic approaches (cosmetic, lacrimal,
orbital)
4. Start with a simple case, for example, an endoscopic eyebrow lift for a woman with a low
hairline and relatively thin skin
5. Properly set up the endoscopic equipment and become familiar with the use of the
endoscope. Adjust the proper focus and lighting. Nothing is worse than not being able to see
accurate anatomy during an endoscopic procedure due to a poor lens or camera
6. Ensure good hemostasis. Hemostasis is critical for endoscopic approaches, and without
hemostasis, the procedure becomes challenging to perform and has a low success rate
7. Have a well-trained assistant to adjust the endoscope, correct any unexpected problems
during the process, and occasionally comment on using different tools
8. As endoscopic interventions are highly instrument dependent, the availability and sterility of
all required instruments should be veried
9. Due to the high cost of repair and replacement, endoscope sets must be handled, cleaned,
and sterilized with care, and the company’s sterilization, maintenance, and cleaning policies
must be followed
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