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Statement of problem Knowledge about the location and dimensions of the mental foramen is important for surgical planning and implant placement in the posterior mandibular region. Purpose The purpose of this clinical study was to assess the location and dimensions of the mental foramen in individuals of different facial type, skeletal class, and sex by means of cone beam computed tomography (CBCT) images. Material and methods CBCT images of 142 individuals (72 women and 70 men) were classified according to the facial type (dolichocephalic, mesocephalic, or brachycephalic) and skeletal class (I, II, or III). The vertical and horizontal locations of each mental foramen were evaluated on panoramic reconstructions, and the greatest height and width of the mental foramen were determined on multiplanar reconstructions. Also, the distances from the mental foramen to the alveolar crest and to the inferior cortex of the mandible were obtained. The data were compared by using the Kruskal-Wallis test and multiway analysis of variance (α=.05). Results The facial type, skeletal class, and sex did not influence the vertical (P=1.00) or the horizontal (P>.15) location of the mental foramen. The most frequent location of the mental foramen was between the first and second premolars and below their apices. The dimensions of the mental foramen were not influenced by the studied factors in men (P>.07); conversely, the mental foramen dimensions were influenced for women (P Conclusions The most frequent location of the mental foramen was between the first and second premolars and below their apices. An influence of the facial type and skeletal class was observed on the dimensions of the mental foramen in women.

Peroneal tendon pathology is commonly associated with chronic lateral ankle instability. Foot and ankle surgeons often rely on preoperative magnetic resonance imaging (MRI) for identification of related pathology and surgical planning in these patients. The purpose of this study was to assess the ability of preoperative MRI to accurately detect peroneal tendon pathology in patients with chronic lateral ankle instability. Consecutive surgical cases involving arthroscopic evaluation and management of lateral ankle instability sequelae were evaluated retrospectively. Preoperative MRI were compared to intraoperative findings in order to determine the sensitivity, specificity, positive and negative predictive values. Eighty-two patients met inclusion criteria, 58 females and 24 males. The average age at the time of surgery was 46 years (range 13-75). Peroneal tendon pathology was identified intraoperatively in 76 (92.7%) patients and on MRI in 40 (48.8%) patients. The most commonly identified pathologies were tenosynovitis, tendinopathy and longitudinal split/tear, with the peroneus brevis tendon being most commonly involved. MRI was 38.7% specific, 50.0% sensitive, had a positive predictive value of 92.5%, and a negative predictive value of 7.1%. While MRI is a helpful study for evaluation of co-pathologies and surgical planning in patients with lateral ankle instability, procedural selection should not be solely based on MRI results, and the peroneal tendons should be evaluated intraoperatively in patients undergoing arthroscopic procedures for lateral ankle instability.

Magnetic resonance imaging (MRI) is increasingly used by the orbital surgeon to aid in the diagnosis, surgical planning, and monitoring of orbital disease. MRI provides superior soft tissue detail compared with computed tomography or ultrasound, and advancing techniques enhance its ability to highlight abnormal orbital pathology. Diffusion-weighted imaging is a specialized technique that uses water molecule diffusion patterns in tissue to generate contrast signals and can help distinguish malignant from benign lesions. Steady-state free precession sequences such as Constructive Interference in Steady-State (CISS) and Fast Imaging Employing Steady-state Acquisition (FIESTA) generate highly detailed, 3-dimensional reconstructed images and are particularly useful in distinguishing structures adjacent to cerebral spinal fluid. Magnetic resonance angiography can be used to characterize vascular lesions within the orbit. New developments in magnetic field strength as well as the use of orbital surface coils achieve increasingly improved imaging resolution.

Preoperative meningioma consistency prediction is highly beneficial for surgical planning and prognostication. We aimed to use magnetic resonance fingerprinting (MRF)-derived T1 and T2 values to preoperatively predict meningioma consistency.A total of 51 patients with meningiomas were enrolled in this study. MRF, T1-weighted imaging, T2-weighted imaging, and diffusion-weighted imaging were performed in all patients before surgery using a 3T MRI scanner. MRF-derived T1 and T2 values, T1-weightd and T2-weighted signal intensities, as well as apparent diffusion coefficient value yield from diffusion-weighted imaging were compared between the soft, moderate and hard meningiomas. Receiver operating characteristic curve analyses were used to determine the diagnostic performance of T1, T2 value, and a combination of T1 and T2 values.After Bonferroni corrections, quantitative T1 and T2 values yielded from MRF were significantly different between the soft, moderate and hard meningiomas (all p0.05). T2 signal intensity was significantly different between the soft and hard, soft and moderate meningiomas (both p0.05), whereas was not significantly different between the moderate and hard meningiomas. However, T1 signal intensity and apparent diffusion coefficient value had no significant differences between the soft, moderate and hard meningiomas (all p0.05). The combination of T1 and T2 values had greater areas under receiver operating characteristic curve curves compared to individual T1 or T2 value.MRF may help to preoperatively differentiate between the soft, moderate and hard meningiomas and may be useful in guiding the surgical planning.

Objective Current published guidelines recommend advanced imaging, specifically, thoracic magnetic resonance imaging (MRI), prior to implantation of epidural paddle spinal cord stimulator (SCS) leads. Preoperative imaging may affect surgical approach to minimize risk of complications. We aimed to assess the impact of preoperative thoracic MRI on surgical planning in a large series of surgical paddle SCS lead placements in a real-world setting. Materials and methods This is a retrospective study of a prospectively maintained data base of 160 patients treated by SCS with awake thoracic surgical paddle lead placement in a single academic functional neurosurgery center from 2013 to 2021. All patients had a thoracic MRI prior to implantation. Abnormal MRI findings were reviewed to determine their potential impact on the safety of surgical paddle lead placement. A minor impact was defined as anatomical areas to avoid with paddle lead placement. Major impacts included significant deviations from standard approach to electrode placement. Results None of the 160 patients had signs or symptoms referable to thoracic spine pathology prior to lead implant. Sixty-seven had abnormal thoracic MRI findings, and 36 had abnormal MRI findings that impacted surgical planning. Thirty-one patients had MRI findings with minor impact. Five patients (more than 3%) had findings with major impact. Conclusions This is the largest case series assessing the impact of preoperative thoracic MRI on surgical planning for patients undergoing paddle SCS placement. Twenty-two percent of patients had MRI findings that impacted surgical planning with 3% requiring additional surgical decompression for safe paddle lead placement. Without advanced imaging to inform surgical planning, unnecessary risk may have been placed on these patients. Although such imaging has been recommended by consensus committees in published guidelines, our study is the first to present a large institutional experience of real-world data that demonstrates its importance.

INTRODUCTION It is critical to preserve adequate vascularization in midface allotransplantation, the major complication of which is inadequate blood supply in palate area supplying mainly by internal maxillary artery. Therefore, the aim of this study is to explore a modified Le Fort II approach entailing midface vascularization enhancement. MATERIALS AND METHODS Ten cadaveric heads were used in mock surgery. A conventional approach was used on seven cadaveric heads to harvest external carotid artery-facial artery-internal maxillary artery axis. On the remaining three cadaveric heads, modified Le Fort II approach was applied where the internal maxillary artery was harvested after cutting off zygomatic arches and rami of the mandible. RESULTS The conventional approach had difficulty harvesting internal maxillary artery, which left the facial artery the only blood supply to midface. Modified Le Fort II approach with Computerized surgical planning (CSP) assisted, on the other hand, could completely unveil and harvest intact internal maxillary artery after osteotomy of mandibular ramus. CONCLUSION The modified Le Fort II approach with CSP and ultrasonic bone cutter assisted can maximally preserve internal maxillary system with ease. This approach optimizes midface allotransplantation in clinical practice in future.

Preoperative assessment is essential to prevent inferior alveolar nerve (IAN) injury during surgical extraction of the lower third molar (LM3). Here, we aimed to establish an assessment system to predict IAN injury during surgical extraction of the LM3. We conducted a retrospective cohort study on 115 patients diagnosed as 'high-risk' based on our previous risk assessment method involving three anatomical features of the inferior alveolar canal using computed tomographic (CT) images. We evaluated the occurrence of neurosensory impairment in these high-risk patients, and its association with novel anatomic features based on CT images. Neurosensory impairments were observed in 19 patients (16.5%). The inferior alveolar canal major diameter (p0.0001) and lingual bone thickness (p = 0.0039) were significantly associated with the occurrence of neurosensory impairment during LM3 extraction. Receiver operating characteristic curves were used to determine cut-off values of these quantitative factors to specifically predict IAN injury. Preoperative risk assessment with quantitative factors based on anatomical features observed on CT images may facilitate more appropriate surgical planning for patients at a high risk of IAN injury.

ObjectiveWe present a semi-automated method for quantifying structural changes after epilepsy surgery that accounts for tissue deformation caused by resection. We demonstrate its utility by comparing the remote structural effects of two surgical approaches, the anterior temporal lobectomy (ATL) and the selective amygdalohippocampectomy (SAH).MethodsWe studied 37 temporal lobe epilepsy (TLE) patients who underwent resective surgery. Patients were treated with either an anterior temporal lobectomy (ATL, N=21) or a selective amygdalohippocampectomy (SAH, N=16). All patients received same-scanner MR imaging preoperatively and postoperatively (5+ months after surgery). To analyze structural changes in remote brain regions, we (1) implemented an automated method for segmenting resections with manual review, (2) applied cost function masking to the resection zone, and (3) estimated longitudinal cortical thickness changes using Advanced Normalization Tools (ANTs). We then compared post-operative changes in cortical thickness between the two surgical groups in brain regions outside the resected area.ResultsPatients treated with ATL exhibited significantly greater cortical thinning globally when compared to patients treated with SAH (p = 0.049). There were significant focal differences between the two treatment groups in the ipsilateral frontal lobe (superior medial and medial orbital regions) and insula (p > 0.001, α = 0.05 Bonferroni corrected). No significant effects were seen in the contralateral hemisphere.SignificanceWe present and share a semi-automated pipeline for quantifying remote longitudinal changes in cortical thickness after neurosurgery. The technique is applicable to a broad array of applications, including surgical planning and mapping neuropsychological function to brain structure. Using this tool, we demonstrate that patients treated with SAH for refractory temporal lobe epilepsy have less postoperative cortical thinning in remote brain regions than those treated with ATL. We share all algorithm code and results to accelerate collaboration and clinical translation of our work.KEY POINTS BOXDifferent epilepsy surgical approaches lead to distinct patterns of postoperative cortical atrophy in remote brain regionsPatients treated with SAH have less postoperative cortical thinning than patients treated with ATLThe insula and frontal lobe demonstrated the greatest focal differences in postoperative cortical thinning when comparing SAH and ATLPostoperative cortical thinning analyses may inform surgical planning and our understanding of cognitive sequelae

Background: Accurate pre-operative staging and correct surgical selection of patients with malignant melanoma reduces unnecessary morbidity and mortality, improves distant control and may improve survival. 18F-fluorodeoxyglucose Positron Emission Tomography Computed Tomography (18F-FDG PET-CT) has been shown to be useful in exclusion of metastatic sites and aids in surgical planning in stage III and potentially resectable stage IV disease. The primary objective of the study was to determine whether the use of PET-CT alters the initial staging and management of patients with advanced and recurrent melanoma. Methods: Retrospective analysis of clinical records of patients with malignant melanoma referred for staging PET-CT over a three-year period at our institution was performed. Pre- and post-PET-CT stage was recorded and a descriptive analysis was done to determine whether PET-CT resulted in a change in stage grouping and whether this change effected a change in clinical management. Results: A change in stage grouping occurred in 21/39 (53.8%) of patients, 76.2% of which were up-staged and 23.8% down staged. On analysis of stage III/IV and recurrent melanoma, a change in stage occurred in 90% of stage III, 50% of stage IV and 50% of recurrent melanoma patients. This effected a change in management in 86.7% of patients with stage III, IV and recurrent melanoma collectively. Conclusion: PET-CT is a useful tool in the staging and subsequent management of melanoma. Its utility is pronounced in advanced and recurrent melanoma.&nbsp

OBJECTIVE Pituitary adenoma is one of the most common primary intracranial neoplasms. Most of these tumors are soft, but up to 17% may have a firmer consistency. Therefore, knowing the tumor consistency in the preoperative setting could be helpful. Multiple imaging methods have been proposed to predict tumor consistency, but the results are controversial. This study aimed to evaluate the efficacy of MR elastography (MRE) in predicting tumor consistency and its potential use in a series of patients with pituitary adenomas. METHODS Thirty-eight patients with pituitary adenomas (≥ 2.5 cm) were prospectively evaluated with MRI and MRE before surgery. Absolute MRE stiffness values and relative MRE stiffness ratios, as well as the relative ratio of T1 signal, T2 signal, and diffusion-weighted imaging apparent diffusion coefficient (ADC) values were determined prospectively by calculating the ratio of those values in the tumor to adjacent left temporal white matter. Tumors were classified into three groups according to surgical consistency (soft, intermediate, and firm). Statistical analysis was used to identify the predictive value of the different radiological parameters in determining pituitary adenoma consistency. RESULTS The authors included 32 (84.21%) nonfunctional and 6 (15.79%) functional adenomas. The mean maximum tumor diameter was 3.7 cm, and the mean preoperative tumor volume was 16.4 cm3. Cavernous sinus invasion was present in 20 patients (52.63%). A gross-total resection was possible in 9 (23.68%) patients. The entire cohort’s mean absolute tumor stiffness value was 1.8 kPa (range 1.1–3.7 kPa), whereas the mean tumor stiffness ratio was 0.66 (range 0.37–1.6). Intraoperative tumor consistency was significantly correlated with absolute and relative tumor stiffness (p = 0.0087 and 0.007, respectively). Tumor consistency alone was not a significant factor for predicting gross-total resection. Patients with intermediate and firm tumors had more complications compared to patients with soft tumors (50.00% vs 12.50%, p = 0.02) and also had longer operative times (p = 0.0002). CONCLUSIONS Whereas other MRI sequences have proven to be unreliable in determining tumor consistency, MRE has been shown to be a reliable tool for predicting adenoma consistency. Preoperative knowledge of tumor consistency could be potentially useful for surgical planning, counseling about potential surgical risks, and estimating the length of operative time.

Summary Background Virtual Surgical Planning (VSP) is increasingly used in maxillomandibular osseous free flap reconstruction. Non-commercial (‘in-house') VSP may offer the same level of accuracy and other benefits, without the inflated costs and time delays inherent in using commercial providers. Comparisons between commercial and in-house methods are lacking. This study aims to determine the accuracy of VSP, comparing in-house and commercially planned cases, and to explore predictors of reconstruction error. Methods 76 patients who had a virtually planned maxillomandibular reconstruction between January 2012 and July 2020 were retrospectively identified. The pre-operative digital plan was compared to the post-operative CT scan in terms of: length of bone segments, angle between adjacent segments and intercondylar and intergonial angle distances (mandibular reconstructions only). Results 44 patients fulfilled the inclusion criteria. The mean intergonial and intercondylar distances error was 1.7 ± 1.01mm, mean segment length error was 1.3 ± 1.40mm, and mean angles error was 1.9 ± 2.32 degrees. The difference in error of in-house VSP compared to commercial VSP was not statistically significant for intercondylar and intergonial distance (p=0.76), segment length (p=0.15), or angle between segments (p=0.92). Increased error was associated with osteoradionecrosis as the indication for surgery, greater number of segments, and secondary reconstructions. Conclusion VSP is an accurate method of maxillary and mandibular reconstruction. In-house VSP may be similar in accuracy to commercial VSP options. Higher levels of inaccuracy are likely to occur in more complex reconstructions, particularly secondary reconstructions, and in the setting of osteoradionecrosis.

Patients with Sjögren syndrome (SS) experience difficulties in wearing conventional dentures. After removal of all teeth, the oral rehabilitation is challenging and time consuming using conventional treatment protocols. Although implant-retained overdentures are beneficial for this specific patient group, the average total oral rehabilitation time (TORT) usually takes at least 9 months and needs to be reduced to increase patients' quality of life (QoL). In this paper, we report on a new treatment concept for immediate implant-based oral rehabilitation in a 77-year-old patient with partial edentulous SS. Because of persistent pain, discomfort, and retention problems with the conventional prosthetic devices, full clearance of the remaining mandibular dentition and immediate oral rehabilitation with an implant-retained overdenture were suggested. The treatment protocol included virtual surgical planning (VSP), combining a guided bone reduction of the mandibular alveolar process, immediate dental implant placement, and restoration using a prefabricated bar and placement of the overdenture. This method demands the use of ionizing 3D imaging optionally combined with an optical dental scan or a conventional impression. Furthermore, one needs to gain experience using VSP software. This novel treatment concept for immediate implant-based oral rehabilitation using VSP proved to be feasible and safe in a patient with SS, resulting in a significantly reduced TORT and improved QoL. Further research is needed to what extent this treatment concept could be beneficial to other patient groups, such as patients with head and neck cancer.

This study was performed to compare the orbital and peri-orbital morphological variations in Apert syndrome patients with different cranial vault suture synostosis, so as to provide an anatomic basis for individualized surgical planning. Computed tomography scans of 57 unoperated Apert syndrome patients and 59 controls were subgrouped as follows: type I, bilateral coronal synostosis; type II, pansynostosis; type III, perpendicular combinations of cranial vault suture synostoses. Orbit bony cavity volume was significantly reduced in type I and type II, by 19% (P 0.001) and 24% (P 0.001), respectively. However, the reduction of orbital cavity volume in type III did not reach statistical significance. Globe volume projection beyond the orbital rim, however, increased by 76% (P 0.001) in type III, versus an increase of 54% (P 0.001) in type I and 53% (P 0.001) in type II, due to different ethmoid and sphenoid bone malformations. Maxillary bone volume was only significantly reduced in type I bicoronal synostosis (by 24%, P = 0.048). Both type I and type II developed relatively less zygoma and sphenoid bone volume. Different cranial vault suture synostoses have varied influence on peri-orbital development in Apert syndrome. Instead of mitigating the abnormalities resulting from bicoronal synostosis in type I, additional midline suture synostosis worsens the exorbitism due to a more misshaped ethmoid.

Background Scapula fracture fixation and implant selection are guided by the fracture pattern and classification which requires accurate understanding and interpretation of the fracture lines. Three-Dimensional (3D) Computed Tomography (CT) based fracture pattern analysis enhances a more accurate understanding of the scapula fracture patterns. The purpose of this study was to create scapula fracture maps and identify the frequent fracture patterns using 3D reconstructed CT images. Method Seventy patients treated for scapular fractures, in a single hospital, were considered for this study. Their CT images were reconstructed into three-dimensional models (3D) and the fracture fragments were virtually reduced. The reduced 3D models were first aligned on a 3D template and 2D images were captured on the Anterior View (AV), Posterior View (PV), and Lateral View (LV). Then each fracture image was aligned on a corresponding 2D template, and the fracture lines were transferred to the template. The three separate views were used to accurately capture the propagation and exit of the fractures through the scapula anatomy. These fracture lines were compiled, and heat maps were generated to identify the frequent fracture zones of the scapula. Result The observed scapula fractures propagated through multiple regions of the bone. Overall, the three most common exit zones in the scapula borders were, lateral border (69%), medial border (67%), and superior border (60%). More specifically, superior lateral border, medial base of the scapula spine, spinoglenoid notch, and mid superior border were the frequent zones of fracture in the scapula body. Simple intraarticular fractures (transverse or oblique type) were the most common (92%) fracture type in the glenoid region. Conclusion Scapula fractures reveal repeatable patterns. The zones of recurrent fracture patterns can be identified from the fracture and heat maps. The graphical plot of fracture and heat maps may assist surgical planning and implant design optimization.

The purpose of this study was to determine whether the use of custom osteosynthesis plates increased the accuracy of proximal segment position following bilateral sagittal split osteotomy in a cohort of 30 patients when compared to a control group of 25 patients who had surgery with conventional plates. Surgery was performed by a single surgeon between October 2015 and December 2017. Post-surgical cone beam computed tomography scans were segmented using Mimics Innovation Suite (Materialise NV), and surface-based superimposition was achieved using ProPlan CMF (Materialise NV). However, there was a tendency for the rotational error to be smaller in the custom group than in the control group. The root mean square error in both groups and for all variables fell within clinical parameters of 2 mm and 4°. In conclusion, the results of this study indicate that customized mandibular fixation plates do not necessarily improve the accuracy of the proximal segments post-surgically; however they may be of benefit in individual patients.

Study Objective Transverse vaginal septae (TVS) are congenital, obstructive anomalies of the vagina typically presenting with abdominal pain and amenorrhea. Currently, the literature about surgical management is sparse. Postoperative complications are common. Vaginal dilation either pre- or postoperatively is sometimes recommended, the outcomes of which are poorly described. The aim of this scoping review was to guide surgical planning, namely, timing and postoperative care, to improve surgical outcomes. Design, Setting, Participants, and Main Outcome Measures This scoping review followed the Joanna Briggs Institute framework. The population of interest was patients 21 years of age or younger with a TVS. MEDLINE, OVID and CINAHL databases were searched using the subject headings listed herein. Literature written in English and French were included. Excluded were reports on patients with concurrent urogenital anomalies or severe developmental disabilities. The resultant articles were reviewed by 2 independent researchers. A third researcher was used in cases of disagreement. Using a descriptive analytical method, data were extracted from the included articles. Results We screened 1441 articles for eligibility; 41 articles met criteria, which described 152 cases of TVS. The most common management was simple vaginal excision. Five studies included outcomes from preoperative dilation, and 11 from postoperative dilation. There were 21 cases of postoperative vaginal stenosis; half (11/21) occurred without postoperative dilation. Conclusion The goal of this review was to describe how TVS are managed and provide guidance for management options. Although the literature was sparse, the authors believe that management in a tertiary center, and surgical delay until the patient is ready to participate in vaginal dilation will improve outcomes for patients with TVS. Further prospective studies are needed to guide surgical planning.

OBJECTIVE Visualization of subcortical language pathways by means of diffusion tensor imaging–fiber tracking (DTI-FT) is evolving as an important tool for surgical planning and decision making in patients with language-suspect brain tumors. Repetitive navigated transcranial magnetic stimulation (rTMS) cortical language mapping noninvasively provides additional functional information. Efforts to incorporate rTMS data into DTI-FT are promising, but the lack of established protocols makes it hard to assess clinical utility. The authors performed DTI-FT of important language pathways by using five distinct approaches in an effort to evaluate the respective clinical usefulness of each approach. METHODS Thirty patients with left-hemispheric perisylvian lesions underwent preoperative rTMS language mapping and DTI. FT of the principal language tracts was conducted according to different strategies: Ia, anatomical landmark based; Ib, lesion-focused landmark based; IIa, rTMS based; IIb, rTMS based with postprocessing; and III, rTMS enhanced (based on a combination of structural and functional data). The authors analyzed the respective success of each method in revealing streamlines and conducted a multinational survey with expert clinicians to evaluate aspects of clinical utility. RESULTS The authors observed high usefulness and accuracy ratings for anatomy-based approaches (Ia and Ib). Postprocessing of rTMS-based tractograms (IIb) led to more balanced perceived information content but did not improve the usefulness for surgical planning and risk assessment. Landmark-based tractography (Ia and Ib) was most successful in delineating major language tracts (98% success), whereas rTMS-based tractography (IIa and IIb) frequently failed to reveal streamlines and provided less complete tractograms than the landmark-based approach (p < 0.001). The lesion-focused landmark-based (Ib) and the rTMS-enhanced (III) approaches were the most preferred methods. CONCLUSIONS The lesion-focused landmark-based approach (Ib) achieved the best ratings and enabled visualization of the principal language tracts in almost all cases. The rTMS-enhanced approach (III) was positively evaluated by the experts because it can reveal cortico-subcortical connections, but the functional relevance of these connections is still unclear. The use of regions of interest derived solely from cortical rTMS mapping (IIa and IIb) leads to cluttered images that are of limited use in clinical practice.

Background This review aims to examine the existing literature to address currently used virtual, augmented, and mixed reality modalities in the areas of preoperative surgical planning, intraoperative guidance, and postoperative management in the field of cardiothoracic surgery. In addition, this innovative technology provides future perspectives and potential benefits for cardiothoracic surgeons, trainees, and patients. Methods A targeted, non-systematic literature assessment was performed within the Medline and Google Scholar databases to help identify current trends and to provide better understanding of the current state-of-the-art extended reality (XR) modalities in cardiothoracic surgery. Related articles published up to July 2020, are included in the review. Results XR is a novel technique gaining increasing application in cardiothoracic surgery. It provides a three-dimensional (3D) and realistic view of structures and environments and offers the user the ability to interact with digital projections of surgical targets. Recent studies showed the validity and benefits of XR applications in cardiothoracic surgery. Examples include XR-guided pre-operative planning, intraoperative guidance and navigation, post-operative pain and rehabilitation management, surgical simulation, and patient education. Conclusions XR is gaining interest in the field of cardiothoracic surgery. In particular, there are promising roles for XR applications in televirtuality, surgical planning, surgical simulation, and perioperative management. However, future refinement and research is needed to further implement XR in the aforementioned settings within cardiothoracic surgery.

Additional resection beyond contrast enhanced lesion on MRI is recently considered to prolong survival in glioblastoma. Prediction of future recurrent site in the peritumoral lesion on preoperative MRI could be useful for surgical planning. The objective of this study was to determine if the preoperative ADC value was associated with the site of future recurrence in patients with glioblastoma. We retrospectively analyzed 21 patients with primary GBM. The ADC value on MRI were analyzed before and after operation and at recurrence. The region of interests (ROIs) were set to cover almost the FLAIR high-signal lesion surrounding contrast enhanced lesion. We determined whether the value of ADC on MRI was correlated with the spot of future recurrence. Among 1844 ROIs determined in the FLAIR high-signal lesion on preoperative MRI, new enhanced lesions occurred in 186 sites. The other 1258 sites showed no change or decrease in size on follow up MRI, and the other 400 sites were removed in first operation. The pre-operative ADC values of sites corresponding to future recurrence were significantly lower than that of non-recurrent sites (p

Background The scalpel sign is a radiological finding observed on sagittal magnetic resonance imaging and computed tomography myelography corresponding to an indentation in the dorsal aspect of the spinal cord resembling a surgical scalpel blade. It is said to be a pathognomonic imaging discovery linked to dorsal arachnoid webs. However, other spine-related conditions may mimic dorsal arachnoid webs on magnetic resonance imaging, such as spinal arachnoid cysts or ventral spinal cord herniation, leading to misdiagnosis. Methods A retrospective review was performed of cases involving 3 different diagnoses at our institution in the last 5 years that shared in common the characteristic focal dorsal indentation of the spinal cord. Results Of 7 cases identified, all but 1 were treated and confirmed intraoperatively. All lesions were located at the dorsal spinal cord. Magnetic resonance imaging was the study of choice for evaluation. Clinical manifestations included back pain and lower extremity numbness and weakness together with compressive myelopathy signs and urinary symptoms. Mean follow-up was 16.8 months with satisfactory postoperative results. Conclusions Isolated radiological presentation of the scalpel sign is not sufficient to distinguish between dorsal arachnoid webs, arachnoid cysts, and ventral herniation of the spine. However, awareness of its importance is relevant for accurate curative surgical planning.

Despite advances in gastrointestinal endoscopic technology, the management of malignant hilar biliary obstruction continues to be a challenge for advanced endoscopists. There has been ongoing debate regarding the optimal modality for both diagnostic and therapeutic interventions in malignant hilar obstruction. Various approaches including endoscopy, interventional radiology guided interventions and surgery are available. The management of malignant hilar biliary obstruction should include a multidisciplinary approach, and both diagnostic and therapeutic interventions should be planned based on whether patient is a candidate for curative surgical resection or not. Understanding the Bismuth-Corlette classification as well as the liver segmental anatomy is crucial for both surgical planning as well as planning endoscopic drainage. Safe and effective endoscopic drainage of malignant hilar biliary obstruction requires a multidisciplinary approach, detailed understanding of liver as well as ductal anatomy, and careful adaptation of any strategy to the individual patient's condition, anatomy, prognosis, and in collaboration with surgery, oncology, and radiology. In this article we review the anatomical concepts and technical considerations that are essential to understand while performing endoscopic retrograde cholangiopancreatography in patients with malignant hilar biliary obstruction.

Automated pancreatic cancer segmentation is crucial for successful clinical aid diagnosis and surgical planning. However, the tiny size and inconspicuous boundaries of pancreatic cancer lesions lead to poor segmentation performance with single-modality imaging. The commonly used registration-based multi-modal fusion strategies may not only introduce uncertainties arising from registration, but also underutilize the complementary information between different modalities. Thus, to achieve different modality-based tumor segmentation, we propose for the first time a registration-free multi-modal and multi-scale adversarial segmentation network (MMSA-Net), which consist of a shared encoder and a dual decoder. Specifically, MMSA-Net combine two complementary modules, inter-modality adversarial learning and intra-modality multi-scale adversarial supervision, to obtain mode-specific segmentation results while facilitating multi-modal fusion. The inter-modality adversarial learning module facilitates the fusion of modality-shared features among different modalities by strengthening the similarity of features extracted by the shared encoder. The intra-modality multi-scale adversarial supervision emphasizes modality-specific features in different decoding paths, inherits and fuses modality-shared features while preserving the feature specificity of each modality, thus outputting competitive modality-specific segmentation results for each modality. Quantitative and qualitative experimental results on multi-parametric MRI pancreatic cancer data show that our method can effectively improve the performance of multi-modal segmentation. The method proposed in this work is expected to be another potential paradigm for addressing multi-modal segmentation tasks in addition to registration. Our source codes will be released at https://github.com/SJTUBME-QianLab/PancreaticCancer_Seg_AdvLearning , once the manuscript is accepted for publication.

The common marmoset has emerged as a popular model in neuroscience research, in part due to its reproductive efficiency, genetic and neuroanatomical similarities to humans and the successful generation of transgenic lines. Stereotaxic procedures in marmosets are guided by 2D stereotaxic atlases, which are constructed with a limited number of animals and fail to account for inter-individual variability in skull and brain size. Here, we developed a frameless imaging-guided stereotaxic system that improves upon traditional approaches by using subject-specific registration of computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) data to identify a surgical target, namely the putamen, in two marmosets. The skull surface was laser-scanned with to create a point cloud that was registered to the 3D reconstruction of the skull from CT. Reconstruction of the skull, as well as of the brain from MR images, was crucial for surgical planning. Localisation and injection into the putamen was done using a 6-axis robotic arm controlled by a surgical navigation software (BrainsightTM). Integration of subject-specific registration and frameless stereotaxic navigation allowed target localisation specific to each animal. Injection of alpha-synuclein fibrils into the putamen triggered progressive neurodegeneration of the nigro-striatal system, a key feature of Parkinson’s disease. Four months post-surgery, a PET scan found evidence of nigro-striatal denervation, supporting accurate targeting of the putamen during co-registration and subsequent surgery. Our results suggest that this approach, coupled with frameless stereotaxic neuronavigation, is accurate in localising surgical targets and can be used to assess endpoints for longitudinal studies.

Clefts involving the mandible and lower lip are very rare, with less than 80 cases having been reported worldwide. The objective of this case report is to highlight this unusual type of facial cleft, and to present the principle features and management typically associated with it. We carefully describe our surgical planning and management of the patient alongside a compilation and comparison of different surgical techniques described in the literature thus far. In this report, we discuss a patient with a cleft of the lower lip, true cleft mandible with independent movements of his mandibular segments, ankyloglossia, and a fistula extending from the mandible to the suprasternal notch complicated with congenital heart abnormalities. We explore the different approaches of when to close the hard and soft tissues, however, there is still no clear surgical protocol for treating cleft mandibles but with more cases and their management and outcomes being reported, this is something which will be useful to develop.

OBJECTIVE Postoperative urinary retention (POUR) is a common complication after spine surgery and is associated with prolongation of hospital stay, increased hospital cost, increased rate of urinary tract infection, bladder overdistention, and autonomic dysregulation. POUR incidence following spine surgery ranges between 5.6% and 38%; no reliable prediction tool to identify those at higher risk is available, and that constitutes an important gap in the literature. The objective of this study was to develop and validate a preoperative risk model to predict the occurrence of POUR following routine elective spine surgery. METHODS The authors conducted a retrospective chart review of consecutive adults who underwent lumbar spine surgery between June 1, 2017, and June 1, 2019. Patient characteristics, preexisting ICD-10 codes, preoperative pain and opioid use, preoperative alpha-1 blocker use, details of surgical planning, development of POUR, and management strategies were abstracted from electronic medical records. A binomial logistic model and a multilayer perceptron (MLP) were optimized using training and validation sets. The models’ performance was then evaluated on model-naïve patients (not a part of either cohort). The models were then stacked to take advantage of each model’s strengths and to avoid their weaknesses. Four additional models were developed from previously published models adjusted to include only relevant factors (i.e., factors known preoperatively and applied to the lumbar spine). RESULTS Overall, 891 patients were included in the cohort, with a mean of 59.6 ± 15.5 years of age, 52.7% male, BMI 30.4 ± 6.4, American Society of Anesthesiologists class 2.8 ± 0.6, and a mean of 5.6 ± 5.7 comorbidities. The rate of POUR was found to be 25.9%. The two models were comparable, with an area under the curve (AUC) of 0.737 for the regression model and 0.735 for the neural network. By combining the two models, an AUC of 0.753 was achieved. With a regression model probability cutoff of 0.24 and a neural network cutoff of 0.23, maximal sensitivity and specificity were achieved, with specificity 68.2%, sensitivity 72.9%, negative predictive value 88.2%, and positive predictive value 43.4%. Both models individually outperformed previously published models (AUC 0.516–0.645) when applied to the current data set. CONCLUSIONS This predictive model can be a powerful preoperative tool in predicting patients who will be likely to develop POUR. By using a combination of regression and neural network modeling, good sensitivity, specificity, and NPV are achieved.

Photodocumentation is an essential part of a rhinoplasty surgeon's practice. Preoperative photographs are an indispensable device for patient counseling and surgical planning. Comparison of preoperative and postoperative photographs allow for outcome evaluation, which has a variety of applications-clinical, research, teaching, medicolegal. The ever-evolving technology of photography may seem daunting, but developing a basic understanding of this tool is imperative for a successful rhinoplasty practice. This article reviews the basic photographic principles, equipment, and techniques that are essential to produce high-quality and standardized patient photographs.

Study design Systematic review and meta-analysis. Objective Historically, posterior approaches to the lumbar spine have allowed surgeons to manage degenerative conditions affecting the lumbar spine. However, spinal muscles injury, post-surgical vertebral instability, cerebrospinal fluid (CSF) leakage, and failed back surgery syndrome (FBSS) represent severe complications that may occur after these surgeries. Lumbar interbody fusion using anterior (ALIF), oblique (OLIF), or lateral (LLIF) approaches may represent valuable surgical alternatives, in case fusion is indicated on single or multiple levels. Methods The present study is a systematic review, conducted according to the PRISMA statement, of comparative studies on OLIF, and LLIF for degenerative spine disorders, and a meta-analysis of their clinical-radiological outcomes and complications. Results After screening 1472 papers on PubMed, Scopus, and Cochrane Library, only 3 papers were included in the present study. 318 patients were included for data meta-analysis, 128 in OLIF group, and 190 in LLIF group. There were no significative differences in terms of surgical (intraoperative blood loss and surgical duration) and clinical (VAS-back, VAS-leg, and ODI scores) outcomes, or fusion rates at last follow-up (> 2 years). Significantly higher rates of abdominal complications, system failure, and vascular injuries were recorded in the OLIF group. Conversely, postoperative neurological symptoms and psoas weakness were significatively more common in LLIF group. Conclusions The meta-analysis suggests that OLIF and LLIF are both effective for lumbar degenerative disorders, although each of them presents specific complications and this should represent a relevant element in the surgical planning.

The primary objective of this article is to explore effects of latest development in the area of three dimensional (3D) printing & to assess its abilities, and further undertake helpful reporting. Here the focus is to assess advantages of 3D printing in orthopedics and analyze how 3D printed models help solve complex 3D orthopedics distortions. This study identified that 3D models manufactured by 3D printing models reduce medical parts development cost and surgical planning time. Integrating 3D printing with orthopaedics helps in understanding the conditions of problems and achieving the operation successfully. This technology can enable doctors/surgeons to design, produce, recreate and plan operations more accurately, carefully, and economically. 3D models can assist specialists with a visual comprehension of the patient-particular pathology and life structures. Innovation in 3D printing initiated a scaffold for the virtual outline and execution of medical procedures. This research proposes the utilisation of 3D printers as an elective procedure for the fabrication of parts. It empowers surgeons/patients for better training, education and research. In the future, there is a foreseeable expansion of additive manufacturing in orthopedics.

Treatment of juvenile hallux valgus can be challenging. Initial treatment with conservative measures is appropriate until exhausted. Surgical treatment should be delayed until after skeletal maturity when possible. Before any intervention, a thorough understanding of the whole patient and any underlying systemic contributors to their hallux valgus, in addition to the radiographic foot parameters, is imperative. Careful and individualized surgical planning should be done to optimize results and decrease the risk for recurrence.

Objective The recent development of extended reality technology has attracted interest in medicine. We explored the use of patient-specific virtual reality (VR) and mixed reality (MR) temporal bone models in anatomical teaching, pre-operative surgical planning and intra-operative surgical referencing. Methods VR and MR temporal bone models were created and visualized on head-mounted display (HMD) and MR headset respectively, by a novel webservice that allows users to convert computed tomography images to VR and MR images without specific knowledge of programming. Eleven otorhinolaryngology trainees and specialists were asked to manipulate the healthy VR temporal bone model and to assess its validity by filling out a questionnaire. Additionally, VR and MR pathological models of petrous apex cholesteatoma were utilized for surgical planning pre-operatively and for referring to the anatomy during the surgery. Results Most participants were favorable about the VR model and considered HMD as superior to a flat computer screen. 91% of the participants agreed or somewhat agreed that VR through HMD is cost effective. In addition, the VR pathological model was used for planning and sharing the surgical approach during a pre-operative surgical conference. The MR headset was worn intra-operatively to clarify the relationship between the pathological lesion and vital anatomical structures. Conclusion Regardless of the participants’ training level in otorhinolaryngology or VR experience, all participants agreed that the VR temporal bone model is useful for anatomical education. Furthermore, the creation of patient-specific VR and MR models using the webservice and their pre- and intra-operative usages indicated the potential of innovative adjunctive surgical instrument.

Background There are significant deficiencies in the evidence base of modern-day osteotomy which result in significant variation in practice between surgeons. The purpose of this statement was to develop a consensus statement on the practice of osteotomy so that a more standardized approach to the indications, surgical technique, and postoperative care could be outlined. The article is also intended to educate and inform the practice of individuals who are early in their experience and/or clinical practice. Method A group of 29 specialist knee surgeons who regularly perform osteotomy was convened to form the Knee Osteotomy consensus Group (KOG). Consensus was determined utilizing the consensus group technique described by List. A total of 37 questions were asked covering all aspects of clinical practice. Results 20 statements were generated and debated until a criterion level of 70% was met. Conclusions Consensus was achieved regarding 20 statements concerning Indications for surgery, decision making, surgical planning, technique, post-operative assessment and recovery.

Introduction Microtia, a congenital anomaly of the auricle with a wide spectrum of presentation with challenging reconstruction. Management depends on its severity with variable reconstructive options. Preoperative planning is crucial to achieve better results and decrease operative time. In this article, we aim to show the utility of an affordable technology with the use of a smartphone, an open-source computer-aided design (CAD) software, and a desktop 3D printer in planning future ear location for unilateral microtia reconstruction in step-by-step fashion. Methodology Facial 3D scanning was done using a smartphone that has a three-dimensional capture system. The scan was then used in an open-sourced CAD software. A mirror image mask was created by reflecting normal side anatomic features to the abnormal side. The mask constitutes the desired area for reconstruction given the ear anthropometrics. Finally, the model was 3D printed and fitted to the patient in which incision marking and framework location was planned. Discussion Ear reconstruction requires careful assessment and specific technicality in its anthropometric measures. One important aspect in surgical planning resides in future ear location that varies between person to person. This variability makes the reconstructive option more customized based on the patient's needs. The utility of CAD software in the measurement and planning can help predict and optimize postoperative results as possible; however, it has major technical demands and added surgical fees. Conclusion Herein, we demonstrate the efficacy of an easy-to-use system beneficial for preoperative planning that is affordable, time-saving, and cost effective.

Background The aim of the current study is to investigate the variations of anatomical (LVRem%) and functional remnant volumes (fLVRem%) and the dynamic uptake of Technetium-Mebrofinate (FRLF) measured from 99m Technetium-Mebrofinate SPECT-CT scan (TMSCT) in patients at high risk of post-hepatectomy liver failure (PHLF). Methods Variations in the measures of LVRem% and fLVRem% were assessed. The predictive accuracies of LVRem%, fLVRem% and FRLF with respect to PHLF were reported. Results From the N = 92 scans performed, LVRem% and fLVRem% returned identical results in 15% of cases, and ±10 percentage points in 79% of cases. Some patients had larger discrepancies, with difference of >10 percentage points in 21% of cases. The difference was significant in those with primary liver cancers (−4.4 ± 9.2, p = 0.002). For the N = 29 patients that underwent surgery as planned on TMSCT, FRLF was a strong predictor of PHLF, with an AUROC of 0.83 (p = 0.005). Conclusion TMSCT is emerging as a useful modality in pre-operative assessment of patients undergoing major liver resection. For those with primary liver cancer, there is a significant variation in the anatomical and functional distributions that needs considered in surgical planning. Reduced FRLF, measured as the dynamic uptake in the future liver remnant, is a strong predictor of PHLF.

INTRODUCTION As computed tomography (CT) usage increases, so have concerns over radiation-induced malignancy. To mitigate these risks, low-dose CT (LDCT) has emerged as a versatile alternative by other specialties, although its use in plastic surgery remains sparse. This study aimed to investigate validated uses of LDCT across surgical specialties and extrapolate these insights to expand its application for plastic surgeons. METHODS A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using search terms "low dose CT" OR "low dose computed tomography" AND "surgery," where the name of each surgical specialty was substituted for word "surgery" and each specialty term was searched separately in combination with the 2 CT terms. Data on radiation dose, outcomes, and level of evidence were collected. Validated surgical applications were correlated with similar procedures and diagnostic tests performed routinely by plastic surgeons to extrapolate potential applications for plastic surgeons. RESULTS A total of 3505 articles were identified across surgical specialties, with 27 ultimately included. Depending on the application, use of LDCT led to a 25% to 97% reduction in radiation dose and all studies reported noninferior image quality and diagnostic capability compared with standard-dose CT. Potential identified uses included the following: evaluation of soft tissue infections, preoperative and postoperative management of facial and hand fractures, flap design, 3D modeling, and surgical planning. DISCUSSION Low-dose CT is a valid imaging alternative to standard-dose CT. Expanded utilization in plastic surgery should be considered to minimize the iatrogenic effects of radiation and to promote patient safety without compromising outcomes.

Ossifying fibroma (OF) is a rare, benign, fibro-osseous lesion of the jawbone characterised by replacement of the normal bone with fibrous tissue. The fibrous tissue shows varying amount of calcified structures resembling bone and/or cementum. The central variant of OF is rare, and shows predilection for mandible among the jawbone. Although it is classified as fibro-osseous lesion, it clinically behaves as a benign tumour and can grow to large size, causing bony swelling and facial asymmetry. This paper reports a case of large central OF of mandible in a 40-year-old male patient. The lesion was treated by segmental resection of mandible. Reconstruction of the surgical defect was done using avascular fibula bone graft. Role of three-dimensional printing of jaw and its benefits in surgical planning and reconstruction are also highlighted.

Purpose There is only limited data on the application of virtual reality (VR) for the evaluation of temporal bone anatomy. The aim of the present study was to compare the VR environment to traditional cross-sectional viewing of computed tomography images in a simulated preoperative planning setting in novice and expert surgeons. Methods A novice (n = 5) and an expert group (n = 5), based on their otosurgery experience, were created. The participants were asked to identify 24 anatomical landmarks, perform 11 distance measurements between surgically relevant anatomical structures and 10 fiducial markers on five cadaver temporal bones in both VR environment and cross-sectional viewings in PACS interface. The data on performance time and user-experience (i.e., subjective validation) were collected. Results The novice group made significantly more errors (p p = 0.001) in cross-sectional viewing than the expert group. In the VR environment, there was no significant differences (errors and time) between the groups. The performance of novices improved faster in the VR. The novices showed significantly faster task performance (p = 0.003) and a trend towards fewer errors (p = 0.054) in VR compared to cross-sectional viewing. No such difference between the methods were observed in the expert group. The mean overall scores of user-experience were significantly higher for VR than cross-sectional viewing in both groups (p Conclusion In the VR environment, novices performed the anatomical evaluation of temporal bone faster and with fewer errors than in the traditional cross-sectional viewing, which supports its efficiency for the evaluation of complex anatomy.

Surgery for nasal airway obstruction (NAO) has a high failure rate, with up to 50% of patients reporting persistent symptoms postoperatively. Virtual surgery planning has the potential to improve surgical outcomes, but current manual methods are too labor-intensive to be adopted on a large scale. This manuscript introduces an automatic atlas-based approach for performing virtual septoplasties. A cohort of 47 healthy subjects and 26 NAO patients was investigated. An atlas of healthy nasal geometry was constructed. The automatic virtual septoplasty method consists of a multi-stage registration approach to fit the atlas to a target NAO patient, automatically segment the patient’s septum and airway, and deform the patient image to have a non-deviated septum. Our automatic virtual septoplasty method straightened the septum successfully in 18 out of 26 NAO patients (69% of cases). In these cases, the ratio of the higher to the lower airspace cross-sectional areas in the left and right nasal cavities improved from 1.47 ± 0.45 to 1.16 ± 0.33 in the region surrounding the septal deviation, showing that the nasal airway became more symmetric after virtual septoplasty. This automated virtual septoplasty technique has the potential to greatly reduce the effort required to perform computational fluid dynamics (CFD) analysis of nasal airflow for NAO surgical planning. Future studies are needed to investigate if virtual surgery planning using this method is predictive of subjective symptoms in NAO patients after septoplasty.

With the rise in popularity of structured reports in radiology, we sought to evaluate whether free-text CT reports on pancreatic ductal adenocarcinoma (PDAC) staging at our institute met published guidelines and assess feedback of pancreatic surgeons comparing free-text and structured report styles with the same information content. We retrospectively evaluated 298 free-text preoperative CT reports from 2015 to 2017 for the inclusion of key tumor descriptors. Two surgeons independently evaluated 50 free-text reports followed by evaluation of the same reports in a structured format using a 7-question survey to assess the usefulness and ease of information extraction. Fisher’s exact test and Chi-square test for independence were utilized for categorical responses and an independent samples t test for comparing mean ratings of report quality as rated on a 5-point Likert scale. The most commonly included descriptors in free-text reports were tumor location (99%), liver lesions (97%), and suspicious lymph nodes (97%). The most commonly excluded descriptors were variant arterial anatomy and peritoneal/omental nodularity, which were present in only 23% and 42% of the reports, respectively. For vascular involvement, a mention of the presence or absence of perivascular disease with the main portal vein was most commonly included (87%). Both surgeons’ rating of overall report quality was significantly higher for structured reports (p

To investigate the impact of virtual reality (VR) technologies on urological surgeries, specifically in the management of prostate cancer and renal cancer. A non-systematic review of the literature was performed. Medline, Pubmed, and the Cochrane Database were screened for studies regarding the use of VR technologies in the management of prostate and renal cancer. In the management of prostate cancer, VR technologies have been increasingly applied for diagnosis with magnetic resonance imaging/ultrasound fusion biopsy, surgical training using a simulator, surgical navigation in robot-assisted radical prostatectomy, and targeted focal therapy. In partial nephrectomy, surgical simulation and intra-surgical guidance with three-dimensional VR have been used for better understanding of the hilar vascular information, tumor location, and positional relationships of the tumor-feeding vessel and pyelocaliceal system. VR contributes to the education, training, and simulation of surgical procedures as well as helping the surgeons to tailor surgical planning on each patient. Further prospective studies are needed to assess the beneficial impacts of this technology for both the physician and patient by objective parameters.

Mandibular symphysis fractures pose several technical challenges for the craniomaxillofacial surgeon. One classic challenge is restoration of the transverse dimension when the mandible is widened secondary to splaying of the lingual cortex. Failure to diagnose or correct this problem can result in widening of the lower facial third, inadequate fracture reduction, and/or a malocclusion. Surgeons have traditionally utilized techniques such as manual pressure to the rami or lingual splint application to address transverse defects intraoperatively. However, these methods may be inadequate in situations with significant widening, such as in the case of concomitant subcondylar fractures. More recently, virtual surgical planning and custom hardware have been utilized to address mandibular widening, though this method also has various shortcomings. In this technical note, the authors present a simple technique using interdental wiring to precisely control mandibular width intraoperatively. The technique is cost effective, does not require an assistant, and can be used in conjunction with any of the above methods. The authors also present a case of secondary reconstruction in which use of this technique was necessary given a large degree of mandibular widening not amenable to reduction and fixation with manual pressure alone.

Purpose To evaluate and compare different surgical approaches for the treatment of Helveston syndrome and provide further information for preoperative planning. Methods From February 2008 to December 2018, data of 52 patients with Helveston syndrome were retrospectively reviewed. Different surgical approaches were selected based on the extent of A-pattern exotropia, dissociated vertical deviation (DVD), and both superior oblique muscle overaction (SOOA) with fundus photograph intorsion. Eye position, A-pattern, DVD, superior oblique muscle function, and binocular vision function were evaluated pre- and postoperatively. The average follow-up duration was 20.5 months. Results Nine cases underwent simultaneous horizontal deviation correction with bilateral superior rectus recession, 24 underwent simultaneous horizontal deviation correction with bilateral superior oblique muscle lengthening, and 19 underwent two stages of horizontal deviation correction with superior oblique muscle lengthening, and later bilateral superior rectus recession. A-pattern, DVD, SOOA, and fundus intorsion were all collapsed in all patients postoperatively. Forty-five patients had an orthophoric eye position with considerably aligned ocular movements postoperatively. The total success rate was 86.5%. Postoperatively, eight of the 10 patients with diplopia experienced a recovery of binocular single vision and three had a recovery of rudimentary stereopsis (Titmus 3000–400 s of arc). The compensatory head posture of patients improved significantly postoperatively. Conclusions The surgical planning of Helveston syndrome should be designed based on the degree of the A-pattern, SOOA, DVD, and the intorsion in fundus photographs, and the appropriate approach should be selected to improve patient satisfaction.

The petrous apex may be affected by a range of lesions, commonly encountered as incidental and asymptomatic findings on imaging performed for other clinical reasons. Symptoms associated with petrous apex lesions commonly relate to mass effect and/or direct involvement of closely adjacent structures. Petrous apex lesions are optimally assessed using a combination of high-resolution CT and MRI of the skull base. Management of petrous apex lesions varies widely, reflecting the range of possible pathologies, with imaging playing a key role, including lesion characterization, surveillance, surgical planning, and oncological contouring.

Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy has revolutionized the survival and the quality of life in selected patients with peritoneal carcinomatosis. Preoperative CT is important for the selection of patients that may benefit from cytoreductive surgery and is useful for surgical planning. There are several tasks for the radiologist during CT interpretation: to describe cancerous implants on a “site-by-site” basis in the peritoneum, ligaments, mesenteries and visceral surfaces, to analyze patterns of involvement and to estimate the disease burden. Knowledge of the correlation between the CT and the surgical findings enhances the understanding of the disease and facilitates the communication between radiologists and surgeons.

Objective : The aim of this study to investigate the benefits of patient-based 3-dimensional (3D) cerebral arteriovenous malformation (AVM) models for preoperative surgical planning and education.Methods : Fifteen patients were operated on for AVMs between 2015 and 2019 with patient-based 3D models. Ten patients’ preoperative cranial angiogram screenings were evaluated preoperatively or perioperatively via patient-based 3D models. Two patients needed emergent surgical intervention; their models were solely designed based on their AVMs and used during the operation. However, the other patients who underwent elective surgery had the modeling starting from the skull base. These models were used both preoperatively and perioperatively. The benefits of patients arising from treatment with these models were evaluated via patient files and radiological data.Results : Fifteen patients (10 males and five females) between 16 and 66 years underwent surgery. The mean age of the patients was 40.0±14.72. The most frequent symptom patients observed were headaches. Four patients had intracranial bleeding; the symptom of admission was a loss of consciousness. Two patients (13.3%) belonged to Spetzler-Martin (SM) grade I, four (26.7%) belonged to SM grade II, eight (53.3%) belonged to SM grade III, and one (6.7%) belonged to SM grade IV. The mean operation duration was 3.44±0.47 hours. Three patients (20%) developed transient neurologic deficits postoperatively, whereas three other patients died (20%).Conclusion : Several technological innovations have emerged in recent years to reduce undesired outcomes and support the surgical team. For example, 3D models have been employed in various surgical procedures in the last decade. The routine usage of patient-based 3D models will not only support better surgical planning and practice, but it will also be useful in educating assistants and explaining the situation to the patient as well.

Primary cardiac sarcomas are very aggressive, being a challenge to cardio-oncology specialty. Surgical planning and innovative techniques have enhanced the possibility of resection. We have described a case of recurrent primary left atrium angiosarcoma, successfully resected with a modified partial autotransplantation technique, planned using a 3-dimensional model created from computed tomography. (Level of Difficulty: Intermediate.), Central Illustration

Choledochal cyst of the cystic duct is a rare anomaly; broadly classified, the pathology may either present as a solitary anomaly or with concomitant involvement of other parts of the biliary tree. In the absence of standard guidelines for surgical planning, the definitive management is based on the experience shared in the literature in the form of case reports and case series. The available options should be discussed with the patient while explaining the possible short- and long-term complications. The authors herewith present two cases of choledochal cyst of the cystic duct along with a review of literature relevant to their etiopathogenesis and its implications for the definitive management.

Background Lipoblastoma is a rare benign mesenchymal tumor of embryonal fat affecting mainly children below 3 years of age. It presents usually as a painless rapidly growing soft lobular mass in the extremities, trunk, and less frequently in the head-neck region. Preoperative imaging is used to assess the extent of disease and aid surgical planning. Complete surgical excision without injury to surrounding vital structures is the treatment of choice. Case presentation We report three interesting lipoblastoma cases: mediastinal lipoblastoma with airway compression and ipsilateral diaphragmatic eventration, neck lipoblastoma with intrathoracic extension, and huge thoracic inlet lipoblastoma with compression of common carotid and Lt subclavian arteries, brachial plexus, and ipsilateral diaphragmatic eventration. Complete excision of lipoblastoma mass was done via neck incision in two cases, and the third case required thoracoscopic excision of intrathoracic remnant 6 months later. All three patients had an excellent outcome. Conclusions Management of cervicothoracic lipoblastoma is a surgical challenge due to the potential for rapid growth and extension to different fascial planes; however, successful excision can be achieved via a neck approach. Complete surgical excision is essential to prevent local recurrence and improve the outcome.

Rationale and objectives Myxofibrosarcoma (MFS) is a common soft tissue sarcoma in the elderly patients with both clinical and magnetic resonance imaging (MRI) peculiar features: very high recurrence rate, relatively low risk of distant metastases. On MRI it shows an infiltrative pattern (“tail sign”) and high myxoid matrix content with water-like appearance on fluid-sensitive sequences. Due to these unusual characteristics, we propose a specific MRI grading system to stratify the risk of local recurrence (LR) and offer other prognostic information. Materials and methods: Two expert radiologists retrospectively and blindly reviewed preoperative MRI of 150 patients affected by MFS of the extremities treated at a single Institution. Myxoid matrix component and contrast enhancement of the tumor were evaluated and graded with a semiquantitative method. The presence of an infiltrative pattern, the depth of the tumor (deep and/or superficial) and tumor sizes were also recorded. MRI features were analyzed separately and correlated to LR risk, sarcoma specific survival and distant metastases rate. Then, according to the statistical significance of the correlation between MRI features and prognosis a 3-grade scoring system was proposed and evaluated to assess the risk of LR. Results: Mean age was 66.1 ± 14.4 years; mean follow-up was 16 ± 28.3 months. The MRI features most associated with higher risk of LR resulted to be: lesion sizes (both volume and maximum diameter with a cut-off of 20 cm – p = 0.01), the “tail sign” (p = 0.045), and high myxoid matrix content with MRI water-like appearance (p = 0.0493). Ninety-four patients (94 of 150- 62.7%) were grade 1, 33 (22.0%) grade 2, and 23 (15.3%) grade 3. Interobserver agreement was substantial with K= 0.779 (95%CI 0.685–0.874). Higher grades of MRI grading system proposed were significantly associated with an increased LR risk, hazard ratio = 2.031 (95%CI 1.366–3.019; p Conclusion: This is the largest series evaluating MRI features as prognostic factors for MFS. The MRI grading system proposed is significantly able to stratify the risk of LR in MFS of the extremities. The system is applicable to all the standard MRI studies protocols, might help in surgical planning, and may offer prognostic information.

The principles of facial reconstruction are well established and some unique modifications apply to the non-White population. Anatomic and physiologic distinctions to this group give rise to alterations in design and surgical planning. Different ethnic groups have different skin anatomy and physiology and that should be taken into consideration. Healing differs among the different ethnic groups, affecting the final result regardless of method chosen. Variations in aesthetic units can lead to different flap selection and design. These should be considered for this population to maximize aesthetic outcomes and patient satisfaction.