Computer Aided Design/Computer Aided Manufacturing-Guided Scapular Tip Free Flap Reconstruction for Complex Maxillofacial Defects.

[BACKGROUND] Reconstruction of maxillary and mandibular defects following oncologic resection remains challenging due to their three-dimensional complexity and critical role in function and aesthetics. The scapular tip free flap (STFF) provides reliable vascularity, substantial bone stock, and chimeric versatility. Computer-Aided Design and Manufacturing (CAD/CAM) has been widely applied in reconstructive surgery to optimize resection accuracy and flap insetting, but its role in STFF supine harvest and inset has never been reported. This report aims to describe the advantages of application of CAD/CAM technology to guide resection and reconstruction in complex maxillary and mandibular oncological defects.

[PATIENTS AND METHODS] We retrospectively analyzed nine patients who underwent maxillary (n = 5) or mandibular (n = 4) reconstruction with STFF between January 2023 and December 2024 at IRCCS Policlinico San Martino, Genoa, Italy. Nine patients of mean age 67.4 years with malignant neoplasms of the mandible (n = 4) or maxilla (n = 5), including squamous cell carcinoma (n = 7) and carcinoma ex inverted papilloma (n = 2), were included in the study. Preoperative virtual surgical planning was performed in collaboration with biomedical engineers to design patient-specific cutting guides and titanium plates. Functional outcomes were assessed using the EORTC QLQ-HN35 questionnaire; morphological accuracy was evaluated by overlay analysis of pre- and postoperative 3D imaging. Operative and ischemia times, complications, and patient-reported satisfaction were recorded.

[RESULTS] All procedures were successfully completed without major intraoperative complications. CAD/CAM-assisted planning enabled precise osteotomies and facilitated flap contouring prior to pedicle division, resulting in reduced ischemia duration and streamlined operative workflow, particularly in mandibular reconstructions. Functional assessments showed preserved swallowing and speech with only mild limitations in social eating and social interaction. Morphological analysis demonstrated high concordance between pre- and postoperative reconstructions, with minimal surface differential in maxillary (range 198-258 mm) and mandibular (range 156-204 mm) bounding boxes, demonstrating satisfactory restoration of facial contour. Patient-reported satisfaction was high across the cohort, ranging from acceptable to excellent.

[CONCLUSION] CAD/CAM-assisted STFF reconstruction allows accurate three-dimensional restoration with shortened operative and ischemia times, leading to predictable functional recovery and favorable aesthetic outcomes. Despite the need for additional preoperative planning and resources, this approach enhances intraoperative efficiency and provides reproducible results, representing a valuable option for selected patients with complex maxillofacial defects.