Virtual surgical planning has transformed jaw reconstruction. Now we need to prove it's worth paying for

Every year, thousands of Australians are diagnosed with head and neck cancer — an estimated 5,577 new cases in 2025 alone, with around 1,377 deaths expected this year. Many of these patients require segmental mandibulectomy as part of their oncological resection. Reconstructing the resultant defect — usually with a free vascularised fibula flap — has long been one of the hardest problems in reconstructive surgery: turning a straight, linear bone into the curvature of the native mandible, maintaining vascularity via microvascular anastomosis, and restoring occlusion, all in a single operation.

For the first 20-odd years of fibula free flap mandibular reconstruction, planning was essentially ‘analogue’: preoperative radiological measurements and intraoperative templating, adjusted by trial and error to obtain the required neo-mandibular shape. Placement of the bone in three-dimensional space with the correct pitch, yaw and tilt took what I'd call a measure of genius, or more commonly, luck. There was a lengthy learning curve, and outcomes were susceptible to imprecision and variability depending on who was holding the saw.

Virtual surgical planning changes the game

Virtual surgical planning (VSP) has changed that. Using high-resolution CT imaging and 3D printing, surgeons can now delineate osteotomies and flap positioning on a computer before the patient ever reaches theatre, generating patient-specific cutting guides, positioning jigs and pre-bent fixation plates. The result is more predictable surgery that depends less on individual surgeon experience — and, in “Jaw in a Day” cases, allows the clinician to plan in reverse, with the desired dental restoration influencing bony flap placement and implant position, so patients can leave hospital with a functioning dental prosthesis already in train.

The evidence backing VSP is genuinely encouraging. Multiple systematic reviews and meta-analyses have linked patient-specific surgical guides and pre-bent fixation plates to reduced operative duration, reduced ischaemia time, fewer postoperative complications and shorter length of stay, with one cost-effectiveness study also reporting reduced operative time. For surgeons earlier in their reconstructive careers, or units with lower case volume, that's a meaningful safety net. VSP also fosters closer collaboration between the resecting and reconstructive teams — it encourages more comprehensive discussions on osteotomy location, vascular pedicle design and donor site selection that used to happen, if at all, on the day of surgery.

Patients at risk of losing access

Most of the studies supporting VSP are small — cohorts of 13 to 30 patients are typical — and most come from overseas health systems with cost structures very different from ours. There is also a lag between image acquisition, virtual planning and eventual implant placement, which can vary from days to weeks. There is, further, an inherent assumption in VSP that biologic systems are inert; cancers can grow between planning and resection, and there is often no capacity to modify the implant if the real-time clinical need varies from the virtually planned solution. And in most Australian centres, VSP still involves outsourcing to an overseas-based manufacturing centre, adding turnaround time, cost, and a degree of clinician disenfranchisement, with reduced oversight by the clinical team.

That last point is where I think the real risk to Australian patients now sits. A Commonwealth review of the guides and implants used in this kind of surgery — the Prescribed List Post-Listing Review of surgical guides and biomodels, performed by the Medical Devices and Human Tissue Advisory Committee — has raised concerns about the disparity between VSP's intended and actual use, and its Stage 2 report has floated restricting access in both the public and private systems. I understand the impulse — funders are right to ask for evidence that a more expensive technology delivers value for money, and robust Australian cost-effectiveness data for VSP in head and neck reconstruction is, frankly, thin on the ground.

Better data needed on real cost

But the answer to thin evidence should be better evidence, not withdrawal of access. If we lose publicly funded VSP because we haven't done the work to justify it, patients undergoing some of the most complex reconstructive surgery we perform will bear the cost — literally, through worse outcomes and longer stays, and figuratively, through a retreat to less precise, more surgeon-dependent techniques we spent 20 years trying to move past.

What I'd like to see now is a coordinated, prospective, Australian effort to capture operative duration, complication rates, length of stay and true whole-of-episode cost for VSP-assisted reconstruction, benchmarked directly against conventional freehand surgery in our own hospitals. Professional bodies and jurisdictional health departments should fund this as a priority, rather than leaving it to individual units to squeeze in alongside their clinical workload. We should also be backing the small number of Australian centres building in-house CAD/CAM capability, which sidesteps some of the cost, turnaround and clinician-disenfranchisement problems that come with outsourcing planning overseas.

VSP hasn't solved every problem in head and neck reconstruction, and it isn't free. But it has made a genuinely difficult operation more precise, more collaborative and more reproducible for the surgeons doing it and the patients relying on it. Before we restrict access to it, we owe those patients the Australian data that tells us what it's actually worth.

Anand Ramakrishnan is Director of the Department of Plastic and Reconstructive Surgery at Royal Melbourne Hospital, a Clinical Associate Professor at the University of Melbourne, and Section Editor (Head and Neck) for the Australasian Journal of Plastic Surgery.

The author has no conflicts of interest to disclose.