Journal of Surgery

Keywords: CAD/CAM (Computer-Aided Design/ComputerAided Manufacturing); Early Recovery after Surgery (ERAS); Extended Reality (XR); Orthognathic Maxillofacial Surgery; Surgery First Approach (SFA); Ultrasonic Bone Aspirator (UBA), Virtual Reality (VR) , , Augmented Reality (AR), Mixed Reality (MR), Hologram, Holoeyes MD

Introduction and Aim

In recent years, there has surged in the demand for orthognathic and maxillofacial surgery due to increasing concerns regarding facial aesthetics. Patients often express dissatisfaction with their appearance and seek urgent improvement. While the Surgery First Approach (SFA) or the Early Surgery Approach (ESA) present potential solutions by promising early aesthetic improvements and reduced treatment duration, their adoption within the limitations of the current insurance system, which prioritizes specific predetermined steps, remains a challenge. To address the diverse needs of patients, our institution established a Class 7 (ISO14644-1) level cleanroom, operating room, and recovery room at Mirise Clinic Minamiaoyama in January 2022, offering orthognathic surgery with a primary approach of 24-hour postoperative management (Figure 1). Traditional postoperative care for orthognathic surgery often involves a week of hospitalization, intermaxillary fixation, enteral nutrition, and, in some cases, Intensive Care Unit (ICU) management with extubation on the following day. In contrast, our study investigates the safety and challenges associated with the 24-hour postoperative management approach implemented for orthognathic surgery at our facility. To improve surgical precision, reduce patient burden, and increase productivity, our facility proactively utilizes various technologies, including Computer-Aided Design (CAD)/ Computer-Aided Manufacturing (CAM), three-dimensional (3D) printers (Figure 2), Ultrasonic Bone Aspirator (UBA) surgical device (Figure 3), and Extended Reality (XR) technology encompassing Virtual Reality (VR), Augmented Reality (AR), and Mixed Reality (MR) (Figure 4). Additionally, we have established a cross-disciplinary team consisting of orthodontists, oral and maxillofacial surgeons, plastic surgeons, anesthesiologists, nurses, dental hygienists, dental technicians, psychological counselors, nursing assistants, and dental assistants (Figure 5). Through close communication and continuous improvements, our aim is to provide high-quality patient care using XR technology in the metaverse (Figure 6). To ensure safety, we have also established partnerships with neighboring university hospitals and general hospitals equipped with ICUs and self-blood storage, creating an emergency flow and environment for rapid and safe response in emergencies.

Figure 1: Operating and Recovery Rooms at Mirise Clinic Minamiaoyama, A: An ISO Class 7 level operating room (ISO14644-1) B: 24-hour post-operative recovery room.

Figure 2: In-house simulation and 3D-printing of orthognathic surgical splints A: Polygon data of a surgical splint for maxillary positioning, produced by simulation software (Materialise PROPLAN CMF and Ortholy DOLPHIN IMAGING) B: High-precision 3D printer “cara Print 4.0 Pro” (Kulzer GmbH, Hanau, Germany). C: In-house 3D-printing of maxillary positioning surgical splints. D: Surgical splint for positioning the maxilla prior to photopolymerization E: Completed maxillary positioning surgical splint.

Figure 3: Precise bone resection and efficient aspiration using an Ultrasonic Bone Aspirator (UBA) A: Intraoperative use of the Sonopet IQ UBA (Stryker, Kalamazoo, MI). B: Console of the ultrasonic aspirator.

Figure 4: Use of an XR head-mounted display during surgery. The Holoeyes MD allows for 3D holographic models of a patient’s specific anatomy, based on surgical simulation results, to be displayed in real space above the sterile surgical field. Their avatars (alter egos) share their opinions and procedures in the metaverse space.

Figure 5: Collaboration among various professions using XR technology in the metaverse. Holoeyes MD, capable of converting patientspecific CT data into 3D holographic images, can be utilized for a range of medical applications, including surgical planning, surgical simulation, and medical education.

Figure 6: Online VR conference in the metaverse space using Holoeyes VS. Dentists and staff members interact via their avatars and share their skills in the metaverse space. A: The multidisciplinary surgical team shares each patient’s 3D data and procedural movements in the metaverse space. B: Surgical procedures are taught using avatars, simulating a face-to-face environment.

Materials and Methods

We performed a retrospective analysis of 42 patients (8 males and 34 females, with females comprising 81% of the cases) aged 14 to 52 years (average age 29.5 years) who underwent orthognathic surgery at Mirise Clinic, Minamiaoyama, between January 2022 and February 2023 using the Surgery First Approach (SFA) or Early Surgery Approach (ESA) (Table 1). We evaluated the surgical duration, bleeding volume, and postoperative complications associated with these procedures.