Precision surgery—balancing risk and impact in maxillofacial surgery

At 40 years old, Jessie, a mother of three, sat in our clinic, facing a complex decision. Diagnosed with an ameloblastoma, she was presented with a conventional approach: radical resection, free flap reconstruction, which would mean a significant change to her appearance and a long recovery. The implications extended beyond surgical risks—they affected her identity, function, and quality of life. I want to share her story to highlight the considerations, how to balance the risks and impact in maxillofacial surgery, and future direction of precision surgery.

Patient-centered innovation is a guiding principle at our practice in Sheba and we decided to pursue an alternative. By leveraging molecular profiling and targeted therapy, we were able to shrink the tumor before surgery, preserving her natural appearance. Instead of radical resection and a free flap reconstruction, she underwent a minimally invasive surgery that maintained her facial contours, reducing functional and aesthetic disruption. This approach not only preserved her ability to eat and speak but allowed her to return to her family with confidence and continuity in her appearance.

Ameloblastoma was the first tumor where we applied this risk-adapted approach. Today, we have extended this methodology to all benign craniofacial tumors, ensuring that each patient receives treatment tailored to oncologic safety and long-term quality of life.

Differentiating risk and sequela in a changing surgical landscape

Risk, in the context of maxillofacial surgery, is the probability that a certain intervention will lead to a suboptimal or unintended outcome. It encompasses both oncologic risk (such as recurrence) and functional risk (such as impaired speech, mastication, or facial aesthetics). Proper risk assessment involves weighing these factors systematically to optimize outcomes while maintaining patient safety.

It is important to differentiate between risk and sequela. Risk refers to the potential for an adverse outcome, such as recurrence or complications, whereas sequela refers to the inevitable consequences of a specific intervention. For example, an aggressive surgical approach may reduce recurrence risk, but it comes with a certainty of functional and aesthetic impairment.

In contrast, a risk-adapted approach that balances oncologic control with tissue preservation might carry a slightly higher potential for recurrence but avoids the guaranteed morbidity associated with overly aggressive treatment.

The role of a multidisciplinary team in maxillofacial surgery

Managing complex craniofacial tumors requires collaboration across multiple disciplines ensuring that each patient benefits from a level of coordinated expertise that defines advanced healthcare systems. A multidisciplinary team approach allows for more comprehensive risk assessment, adaptive treatment strategies, and improved patient-centered care.

Key members of the team include:

Maxillofacial surgeons—responsible for risk-adapted surgical planning and reconstructive techniques

Medical oncologists—guide the use of targeted therapies and systemic treatments pre- and post-operatively

Radiologists—monitor tumor progression and treatment response through advanced imaging, pinpointing the optimal timing of surgical intervention

Pathologists—conduct molecular profiling and histopathologic analysis to refine diagnoses and treatment planning

Effective teamwork is crucial in dynamically adapting treatment protocols to each patient’s unique needs. By integrating expertise across fields, we can make informed, calculated decisions that balance oncologic control with the highest possible functional and aesthetic outcomes.

A stepwise approach to precision surgery

The implementation of precision surgery begins with a structured, data-driven approach to evaluating and treating craniofacial tumors. The key steps in this methodology include:

1. Molecular Profiling—understanding tumor biology: Before any surgical intervention, we perform molecular profiling to identify key mutations that drive tumor behavior. For example, BRAF V600E mutations in ameloblastomas have been linked to responsiveness to targeted inhibitors. Similarly, SMO and PTCH1 mutations in odontogenic tumors provide valuable insights into potential therapeutic pathways. Understanding the genetic makeup of the tumor allows us to tailor treatment strategies accordingly.
2. Targeted Therapy—shrinking the tumor before surgery When an actionable mutation is identified, systemic therapy can be initiated preoperatively to reduce tumor burden. Targeted therapies, such as BRAF inhibitors for ameloblastoma or Hedgehog pathway inhibitors for odontogenic tumors, can significantly shrink tumors, thereby preserving healthy tissue and reducing the extent of resection required. 
3. Bone Regeneration and Reconstruction Optimization: One of the unexpected benefits of targeted therapy is that, in some cases, bone regeneration is observed when the tumor shrinks. Instead of relying solely on grafting and reconstruction, we can leverage the body's natural regenerative capacity, reducing morbidity and improving patient outcomes.
   Risk-Adapted Surgical Planning: Using risk matrices and functional outcome analysis, we determine the optimal balance between oncologic control and tissue preservation. This ensures that each case is managed based on individual risk factors rather than standardized protocols, allowing for a more personalized approach to surgery.
4. Real-Time Decision-Making During Surgery: Rather than committing to a single plan preoperatively, we integrate intraoperative findings and imaging to guide the extent of resection. reflecting a dynamic, patient-adaptive approach that prioritizes both medical precision and ethical responsibility.  This flexibility allows us to adapt the surgery dynamically based on real-time tissue response.
5. Postoperative Surveillance and Functional Outcome Measurement: Beyond recurrence monitoring, we incorporate Patient-Reported Outcome Measures (PROMs) to evaluate speech, mastication, and aesthetics, ensuring that surgical success is defined not only by oncologic control but also by patient quality of life.

A structured approach to risk allows us to individualize treatment rather than apply a rigid, one-size-fits-all protocol. Patients should be active participants in risk assessment, understanding that taking a calculated risk—such as opting for neoadjuvant therapy to shrink a tumor before resection—can significantly improve their quality of life. Shared decision-making ensures that surgeons and patients align on priorities, balancing the need for oncologic control with the benefits of functional preservation.

The future of maxillofacial surgery: a shift in risk assessment

For years, maxillofacial surgery has been guided by a principle of maximal resection for minimal recurrence. However, as our understanding of tumor behavior and functional rehabilitation deepens, this model is evolving.

We can redefine risk, ensuring oncologic control while prioritizing patient functionality. We can move beyond recurrence as the sole metric, integrating patient-reported outcomes and functional restoration into success criteria.

We will develop risk-adapted, precision-driven strategies, leveraging real-time data and molecular profiling to personalize treatment. In a field that balances oncologic necessity with reconstructive precision, the ability to manage risk dynamically is key—an approach that ensures patients are treated with both technical excellence and an unwavering commitment to their long-term well-being. As surgeons, our responsibility is to continuously evaluate and refine our approach to maximize both oncologic safety and functional outcomes.

Established surgical protocols continue to serve as the foundation of care; however, incorporating molecular profiling and patient-specific risk factors allows for a more refined and individualized therapeutic approach—broadening treatment possibilities and enhancing clinical outcomes. This ensures that treatment strategies remain evidence-based while allowing for individualized decision-making that prioritizes both oncologic safety and functional outcomes. The challenge ahead is not whether we can adopt these strategies, but how effectively we implement them to benefit every patient who entrusts us with their care.