Учебники / Computer-Aided Otorhinolaryngology-Head and Neck Surgery Citardi 2002

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increased computational power of several orders of magnitude to perform segmentation and render images in real-time. Given the persistent exponential increases in computing power since the invention of the transistor, the time until this dream can be realized is not as far off as many would think.

19.5.2 Potential Future Applications

It is extremely difficult and foolhardy to predict the future, and attempts to forecast how VE will advance and how it will be applied in coming years will probably be no more successful than predicting the direction of the economy or forecasting the weather. The further out one looks, the less predictable the result. Nevertheless, VE is a flexible tool that provides a unique way to visualize anatomy and pathological changes, and this flexibility indicates that it can be adapted to a wide variety of applications. There are several exciting areas where further study and development of VE will likely lead to valuable clinical applications for otolaryngologists in the future.

19.5.2.1 Development of Teaching Applications

The visualizations produced by VE can be used in a variety of educational applications, ranging from teaching normal anatomy to medical students to evaluating complex anatomical variations and pathology by seasoned clinicians. VE images can be viewed in conjunction with standard axial, coronal, and sagittal images to provide radiologists and clinicians additional views that enhance the understanding of normal and abnormal anatomy. VE data can be incorporated into computerized atlases cataloguing normal and pathological cases. Integration with virtual reality software applications could allow immersion into the anatomical structures to facilitate learning of complex 3D anatomical relationships. These cases could also be integrated with the virtual human project data sets provided by the National Library of Medicine. This is a set of complete digital models of the human body constructed from high-resolution cross-sectional images of human male and female cadavers. CT, MRI, and anatomical cross-sectional data are available for the entire body with 3D resolution of approximately 1 mm. These data can be downloaded off the Internet and processed using image rendering software [65,80].

19.5.2.2 Surgical Simulators

Surgical training is another application where VE can play a role [76]. Hopper et al. demonstrated electronic tissue removal from paranasal sinus VE studies to simulate surgical intervention and visualize deeper structures with the VE study [56]. With further advances, it will become possible to perform rehearsals of complete operations at a workstation using patient-specific data prior to taking

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the patient to the operating room. The use of surgical training simulators (see Chapter 7) for teaching and skill assessment is also undergoing rapid development [55,81–83]. Surgical simulators provide an interactive 3D virtual reality environment that also allows real-time interaction and tactile feedback (haptics) to endoscope or instrument manipulation within the virtual environment. This allows the virtual surgeon not only to visualize, retract, cut, and cauterize tissues, but also to receive tactile feedback that is a critical part of the surgical experience. One simulator system developed for endoscopic sinus surgery utilizes data from the visible human data set to construct a virtual environment [83]. It may be feasible to adapt surgical simulators to incorporate VE data and construct a library of simulations based on patient-specific VE studies. Having a number of patientspecific databases could allow creation of a portfolio of different scenarios a surgeon is likely to encounter, in a fashion analogous to different weather conditions or equipment malfunctions provided to aircraft pilots in flight simulators. This has the potential to enhance the realism of surgical simulators to improve teaching and is an area that is largely unexamined at this time.

19.5.2.3 Additional Potential Applications

CT and MRI data are used in stereotactic systems in the operating room for anatomical localization. Current systems display 3D location on a monitor showing composite axial, coronal, and sagittal images. It is possible that integrating VE data and currently available stereotactic software used intraoperatively to provide precise 3D anatomical localization in real time might enhance the utility of these localization systems. Positional information obtained using stereotactic image localization techniques could be utilized to merge optical images seen through the endoscope with radiographic VE images to form a composite image. In fact, the SAVANT surgical navigation platform (CBYON, Palo Alto, CA), a system that is currently available, can register endoscopic images generated by perspective volume rendering of preoperative data with the view through a standard nasal telescope. In this system, the SAVANT tracks telescope position and registers the virtual endoscopic view to the real work endoscopic view. This may allow the surgeon to potentially see through the tissues in the operative field. Jolesz et al. demonstrated a simple application of the concept of image-guided endoscopy in a patient with a retropharyngeal tumor requiring endoscopy-guided intubation [77]. A small electromagnetic sensor was attached to the tip of a fi- beroptic endoscope. The endoscope was introduced with an endotracheal tube, and the position of the tube tip was registered to data from a VE study. The progress of the intubation was monitored using data obtained from the VE study to guide the endotracheal tube placement.

Computerized radiation therapy treatment planning systems may also be able to incorporate VE data to enhance the speed and accuracy of radiation treat-

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ment planning. Potential applications include selection of treatment fields, planning beam paths, and monitoring of treatment response.

Robotic or remote (telepresence) surgery is an exploding technology that is starting to be applied clinically [84–88]. It is conceivable that VE information can be successfully incorporated with computerized surgical systems to allow telepresence surgery. There are many unexplored areas where VE could be utilized to enhance the effectiveness of existing technologies.

Poor contrast resolution between tissues is a limiting factor with imaging modalities in current use. The limited ability to define tumor from normal or inflamed tissues and difficulties encountered trying to separate anatomical structures from the surrounding tissue are technical hurdles that limit the quality of VE studies. One new technology that may eventually be able to improve tissue resolution is MR spectroscopy (MRS). MRS has the potential to noninvasively discriminate between normal and malignant tissues based on functional properties of the tissues. Studies in the prostate [89–92], breast [93], and cervical lymph nodes [94] demonstrate successful spatial discrimination of tumor from normal tissues. If very specific high-resolution discrimination of tumor margins becomes possible with MRS, there is potential for incorporation into VE to map tumors and evaluate potential recurrences.

19.6SUMMARY

VE provides a new way of visualizing anatomy and pathological changes and represents the convergence of advances in optical endoscopy, radiology, and computer science and technology to provide a realistic visualization of radiographic anatomy with the viewpoint of a person inside the imaged structure. The methodologies behind VE combine techniques from the fields of computer graphics and image processing to provide realistic perspective views of crosssectional image data applicable to a wide variety of both medical and nonmedical applications. VE is perhaps best thought of as an adaptable and flexible imaging tool that provides a new way to view anatomy and pathological changes.

Three-dimensional perspective rendering of luminal anatomy has been tested in a number of body sites, and the technique is rapidly evolving. New applications are being evaluated, and the advantages and disadvantages of this new technology are being assessed. VE has potential clinical applicability in a number of areas in the head and neck region. Further advances in technique and marriage of VE with other technologies, including surgical localization systems, surgical simulators, computerized radiation therapy equipment, telepresence surgery applications, and MR spectroscopy, to name a few, may eventually make VE an indispensable tool for future generation of clinicians. It is difficult to predict how VE will evolve and how it will ultimately be utilized, but it is very

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likely that this new technology will play an increasing role in clinical medicine in the future.

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20

Computer-Aided Facial Plastic

Surgery

Daniel G. Becker, M.D.

University of Pennsylvania, Philadelphia, Pennsylvania

Madeleine A. Spatola, M.A.

Thomas Jefferson University Medical School,

Philadelphia, Pennsylvania

Samuel S. Becker, M.F.A.

University of California at San Francisco Medical Center, San Francisco, California

20.1INTRODUCTION

The most obvious example of the nearly universal incorporation of computer technology into facial plastic surgical practices is office software and computer systems, which provide valuable benefit for the surgical practice seeking to deliver efficient state-of-the-art care. Computer technology is playing an increasing role in communication with patients and colleagues and also in education. In the area of photodocumentation—a critical component in facial plastic surgery— digital technology now provides an alternative to the time-tested 35 mm single lens reflex (SLR) camera. Digital photography and computer photo archiving are allowing easier storage and retrieval of photographic images for improved documentation, self-education, and communication. Computer imaging has be-

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