Improving Reconstructive Surgery through Computational Modeling of Skin Mechanics

2020-07-30T05:06:43Z (GMT) by Taeksang Lee
Excessive deformation and stress of skin following reconstructive surgery plays a crucial role in wound healing, often leading to complications. Yet, despite of this concern, surgeries are still planned and executed based on each surgeon's training and experience rather than quantitative engineering tools. The limitations of current treatment planning and execution stem in part from the difficulty in predicting the mechanical behavior of skin, challenges in directly measuring stress in the operating room, and inability to predict the long term adaptation of skin following reconstructive surgery. Computational modeling of soft tissue mechanics has emerged as an ideal candidate to determine stress contours over sizable skin regions in realistic situations. Virtual surgeries with computational mechanics tools will help surgeons explore different surgeries preoperatively, make prediction of stress contours, and eventually aid the surgeon in planning for optimal wound healing. While there has been significant progress on computational modeling of both reconstructive surgery and skin mechanical and mechanobiological behavior, there remain major gaps preventing computational mechanics to be widely used in the clinical setting. At the preoperative stage, better calibration of skin mechanical properties for individual patients based on minimally invasive mechanical tests is still needed. One of the key challenges in this task is that skin is not stress-free in vivo. In many applications requiring large skin flaps, skin is further grown with the tissue expansion technique. Thus, better understanding of skin growth and the resulting stress-free state is required. The other most significant challenge is dealing with the inherent variability of mechanical properties and biological response of biological systems. Skin properties and adaptation to mechanical cues changes with patient demographic, anatomical location, and from one individual to another. Thus, the precise model parameters can never be known exactly, even if some measurements are available. Therefore, rather than expecting to know the exact model describing a patient, a probabilistic approach is needed. To bridge the gaps, this dissertation aims to advance skin biomechanics and computational mechanics tools in order to make virtual surgery for clinical use a reality in the near future. In this spirit, the dissertation constitutes three parts: skin growth and its incompatibility, acquisition of patient-specific geometry and skin mechanical properties, and uncertainty analysis of virtual surgery scenarios.
Skin growth induced by tissue expansion has been widely used to gain extra skin before reconstructive surgery. Within continuum mechanics, growth can be described with the split of the deformation gradient akin to plasticity. We propose a probabilistic framework to do uncertainty analysis of growth and remodeling of skin in tissue expansion. Our approach relies on surrogate modeling through multi-fidelity Gaussian process regression. This work is being used calibrate the computational model against animal model data. Details of the animal model and the type of data obtained are also covered in the thesis. One important aspect of the growth and remodeling process is that it leads to residual stress. It is understood that this stress arises due to the nonhomogeneous growth deformation. In this dissertation we characterize the geometry of incompatibility of the growth field borrowing concepts originally developed in the study of crystal plasticity. We show that growth produces unique incompatibility fields that increase our understanding of the development of residual stress and the stress-free configuration of tissues. We pay particular attention to the case of skin growth in tissue expansion.
Patient-specific geometry and material properties are the focus on the second part of the thesis. Minimally invasive mechanical tests based on suction have been developed which can be used in vivo, but these tests offer only limited characterization of an individual's skin mechanics. Current methods have the following limitations: only isotropic behavior can be measured, the calibration problem is done with inverse finite element methods or simple analytical calculations which are inaccurate, the calibration yields a single deterministic set of parameters, and the process ignores any previous information about the mechanical properties that can be expected for a patient. To overcome these limitations, we recast the calibration problem in a Bayesian framework. To sample from the posterior distribution of the parameters for a patient given a suction test, the method relies on an inexpensive Gaussian process surrogate. For the patient-specific geometry, techniques such as magnetic resonance imaging or computer tomography scans can be used. Such approaches, however, require specialized equipment and set up and are not affordable in many scenarios. We propose to use multi-view stereo (MVS) to capture patient-specific geometry.
The last part of the dissertation focuses on uncertainty analysis of the reconstructive procedure itself. To achieve uncertainty analysis in the clinical setting we propose to create surrogate and reduced order models, especially principal component analysis and Gaussian process regression. We first show the characterization of stress profiles under uncertainty for the three most common flap designs. For these examples we deal with idealized geometries. The probabilistic surrogates enable not only tasks such as fast prediction and uncertainty quantification, but also optimization. Based on a global sensitivity analysis we show that the direction of anisotropy of skin with respect to the flap geometry is the most important parameter controlled by the surgeon, and we show hot to optimize the flap in this idealized setting. We conclude with the application of the probabilistic surrogates to perform uncertainty analysis in patient-specific geometries. In summary, this dissertation focuses on some of the fundamental challenges that needed to be addressed to make virtual surgery models ready for clinical use. We anticipate that our results will continue to shape the way computational models continue to be incorporated in reconstructive surgery plans.