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Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis.Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment.Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot.This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.

Giant-cell tumor (GCT) is locally aggressive bone neoplasm, with an unpredictable pattern of biological aggressiveness. The optimal treatment had to achieve a negligible local recurrence rate while maximizing musculoskeletal function. Numerous options for reconstruction are available, but in the literature there is a lack of salvage surgery data. We present a case of a 67-year-old woman who underwent complete wrist arthrodesis with vascularized fibular graft as salvage procedure for allograft necrosis, after excision of a distal radius GCT. The patient did not complain of any impairment in daily use, and the functional score was 22 points (73%) at latest follow-up of 14 months. Despite joint salvage remains the most favorable treatment with regard to functional outcome for aggressive tumors of the distal radius, vascularized fibular grafts is a valuable alternative especially in salvage procedures, where the use of another allograft could lead to higher complications rate. Keywords: Vascularized fibular graft, Wrist arthrodesis, Giant-Cell Tumor, Fibula free flap.

Background Total wrist fusion (TWF) is indicated for longstanding degenerative, posttraumatic and/or post-oncological conditions to provide pain relief and wrist stability at partial expense of wrist motion. Patients and Methods A total of 11 consecutive patients who had completed TWF with Vascularized Fibula Graft (VFG) for massive distal radius defects were identified retrospectively from our centre using inpatient records. We evaluated bone fusion times and long term functional outcomes following the procedure. Post-operative grip strength (GS) and prono-supination were objectively measured. The new Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to rate disability and symptoms; pre- and post- operative pain with the Visual Analog Scale (VAS) was assessed. A literature review of the present studies about TWF with VFG was performed, with the aim of comparing long-term functional results of the surgical techniques so far reported in the English literature. Results Our experience with TWF using VFG appeared slightly better than that found in the literature. The procedure was successful in all the cases, achieving bone union in 4,8 months on average. Complication rate was 27,2%, no flap loss was recorded. There were no wrist instability, deformation or dislocation; mean pronation/supination (P/S) was 57,5°/61,2°. Average grip strength resulted 59% of the contralateral side. Mean recorded levels of visual analog scale (VAS) for pain postoperatively were 2,32 ± 0,792, which improved significantly from the pre-operatively value of 7,90 ± 0,79. Mean overall satisfaction was good and all the patients comfortably returned to normal activities. Conclusions Wrist arthrodesis by means of VFG resulted to be an effective and reliable option in dealing with massive defects of distal radius with involvement of radio-carpal joint. Although the cohort analyzed is relatively small and definitive conclusions cannot be drawn, the long term radiographs and the overall functional outcomes encourage to use the described surgical option over other techniques, such as prosthetic replacement and non-vascularized bone grafts.

Microsurgery has become standard of care for increasingly complex techniques in tissue harvest, replantation, reconstruction, allotransplantation, and supermicrosurgery on submillimetric vessels. As techniques become more and more challenging, and are performed at smaller and smaller scale, there is greater potential application for robotic assistance in extreme motion scaling and tremor reduction.The Symani Surgical System (Medical Microinstruments, S.p.A, Calci, Pisa, Italy), a robotic platform designed for microsurgery, was used in a robotic-assisted microsurgical free-flap reconstruction using a perforator-to-perforator flap technique. This procedure employed robotic-assisted anastomosis of an artery and vein.The procedure was completed successfully, with vessels fully patent immediately following and 20 minutes after anastomosis. The flap was viable, no re-exploration of the anastomosis was necessary postoperatively and no flap loss occurred.This novel, dedicated robotic platform with wristed microsurgical instruments was shown to be feasible for carrying out robotic-assisted anastomosis of veins and arteries below 0.8mm in diameter, in the domain of supermicrosurgery. The system has the potential to open the field of microsurgery to new clinicians and to facilitate new microsurgical applications that were previously rendered inaccessible by the limits of manual precision and physiological tremor.The Symani System was loaned to the Plastic, Reconstructive and Microsurgery unit at CTO Careggi University Hospital by MMI SpA, and the necessary robotic instrumentation was provided free of charge for use in this case.

Head and neck reconstruction poses unique challenges in rehabilitating surgical defects in terms of integrity, function, and form. The radial forearm free flap (RFFF) has been widely used for defect coverage, especially in the head and neck area, but its versatility allows it to be used for soft-tissue reconstruction in various parts of the body. The vascular features of the flap are quite constant and reliable. Nevertheless, abnormalities of the forearm vascular tree have been described over the decades. We report a case of intraoral reconstruction after verrucous carcinoma recurrence in a 74-year-old woman with an unusual forearm flap, which we called the median forearm free flap, based on a median branch of the radial artery that was preoperatively detected using handheld Doppler ultrasonography. The distally located skin paddle was predominantly supplied by the aberrant median vessel with its perforators. The flap was thus safely harvested with this atypical pedicle. Successful reconstruction of the intraoral defect was achieved, with an uneventful postoperative course.

Reconstruction after maxillofacial trauma is extremely challenging. During the past several decades, the chimeric fibular-free flap has emerged as a leading reconstructive option for head and neck compound defects. This report describes a unique case of total mandibular reconstruction using a double-paddle osteocutaneous fibular free flap after facial traumatic injury. A 45-year-old man presented a severe maxillofacial trauma with complete mandibular avulsion. The shortest segment of a 24-cm fibular flap was used to reconstruct the symphysis while the longest segments were placed to rebuild the mandibular body. Microvascular anastomoses were performed with the external jugular vein and facial artery. The distal skin island (10 × 5 cm) was sutured to cover the endo-oral defect while the proximal one (12 × 6 cm) to restore the external tissues continuity of the facial lower third. The postoperative course was uneventful. One year after flap reconstruction, a first commissuroplasty was performed. After 3 months, secondary commissuroplasty was performed with an Estlander flap to rebuild the right lower lip. At latest follow-up, 60 months postoperatively, the patient was able to tolerate soft diet with maximal mouth opening of more than 4 cm; no impairment to mastication, deglutition, or phonation was observed. Speech was normal and the aesthetic outcome was judged good. Double-paddle fibular free flap allows reconstruction of extremely challenging defects, such in case of complete mandibular avulsion. The proximal perforator can provide extended soft-tissue coverage and greater volume than traditional osteocutaneous flaps, avoiding two flaps simultaneous harvest.

INTRODUCTION Pelvic ring reconstruction after internal hemipelvectomy is an extremely challenging surgical procedure, and mandatory reconstruction is to provide a durable and pain-free functional outcome, especially for young, active patients. One of the most widely employed techniques is reconstruction with a double-barreled fibular free flap (DBF). The aim of our work was an in-depth analysis of the outcome of pelvic ring reconstruction performed using the above-mentioned method, in particular looking for a correlation between the fixation technique and either ambulation status or complications. MATERIALS AND METHODS A systematic review was performed in November 2020 using PubMed and MedLine Ovid databases according to the PRISMA guidelines and the results were statistically analyzed. RESULTS Studies were published between 1994 and 2015. A DBF was used in each case, with a total of 30 patients. Reconstruction was performed with screws in 13 cases, Cotrel-Dubousset rod fixation in 6, screws and plate in 5, screws with external fixation in 4, and ISOLA in 2. Follow-up time ranged from 3 to 131 months. Functional outcome was excellent in 4 patients and good in 26 patients. Statistical analysis showed no statistical evidence of existing correlation between fixation technique and complications (p = .873), while statistical correlation between age and fixation technique was found (p

Microsurgery (MS) is a discipline addressed by many specialties and it is our interest to be able to carry out a pedagogical assessment of the Master Degree in Reconstructive Microsurgery (MRM) as a training program in MS.The MRM is a hybrid, blended program (virtual and face-to-face), developed in 12 modules, over a 2-year duration, which completes 2625 hours. This program is directed by recognized professors in the discipline from different parts of the World and enrolls 35 students per edition.The program reserves 35% of the places for students from emerging countries. Once each of the modules has been received and the exams passed, the students will undergo a period of clinical immersion in the reference centers around the world and after defending the research project they will be able to receive the distinction of the Master granted by the Autonomous University of Barcelona (UAB).There have been 11 editions of MRM since 2009 without interruption, with an enrollment of 400 students, 83% received the MRM degree. 65% work as Microsurgeons. 60% were Men and 40%, Women. 32% have become MS leaders in each region.We consider that the MRM is a solid, reproducible and adaptable program that guarantees each one of the pedagogical aspects. The program is unique and brings together all the qualities so that students have the necessary tools and thus make a safe start in MS.

Background: Painful conditions such as neuroma pain, stump pain, and phantom limb pain (PLP) can manifest after amputation and are termed generally as post-amputation pain. The mechanisms underlying post-amputation pain are diverse and should be addressed accordingly. Different surgical treatment methods have shown potential for alleviating neuroma pain and at lesser degree stump pain and PLP. Two reconstructive surgical interventions, namely Targeted Muscle Reinnervation (TMR) and Regenerative Peripheral Nerve Interface (RPNI), are gaining popularity in post-amputation pain treatment with promising results. However, these two methods have not been directly compared in a randomised controlled trial (RCT). Here, we present a study protocol for a double-blind RCT to assess the effectiveness of TMR, RPNI, and a non-reconstructive procedure called neuroma transposition as an active control in alleviating neuroma pain, stump pain, and PLP. Methods: Seventy-five upper and lower limb amputees suffering from post-amputation pain, are recruited, and randomly assigned to one of the surgical interventions (TMR, RPNI, or neuroma transposition) in an equal allocation ratio. Complete evaluations are performed during a baseline period prior to the surgical intervention and follow-ups are conducted in short-term (one-, three-, six-, and twelve-months post-surgery) and in long-term (three- and five-years post-surgery). After the twelve-months follow-up, the study is unblinded for the evaluator and the participants. If the participant is unsatisfied with the outcome to treatment at that time, further treatment including one of the other procedures will be discussed in consultation with the clinical investigator.Discussion: A double-blind RCT is necessary for the establishment of evidence-based procedures, hence the motivation for this work. In addition, studies on pain are challenging due to the subjectivity of the experience and the lack of objective evaluation methods. Here, we mitigate this problem by including several different pain evaluation methods known to have clinical relevance. We decided to analyse the results using an adherence to protocol approach (per-protocol, PP), as this is more suitable than intention-to-treat (ITT) in pain studies with long-term follow-ups. This is because patients often experience initial pain relief post-surgery, but over time, gradually returns to pre-surgical levels. This could lead to misinterpretation of the clinical reality. We will instead report the actual values of pain and number of participants in each follow-up. Trial registration: ClincialTrials.gov, NCT05009394.

The propeller flap is an island of skin that is raised on its pedicle (most commonly a single perforator) and can rotate 180 degrees to cover a soft tissue defect. Thanks to these features, the propeller flap brings reliable tissue from outside of the zone of injury while sparing the main vessels of the upper extremity. This technique limits the donor site to the same limb, captures skin characterized by having the same color and texture, does not necessarily need a microvascular anastomosis, and overall reduces the operating time and surgical cost. Our intent here is to present 27 cases with different soft tissue defects of the upper arm and forearm that have been successfully reconstructed using propeller flaps. The surgical technique, with emphasis on the anatomy of the upper arm, is described. In particular, use of a freestyle approach to customize a perforator-based propeller flap to cover defects from small to medium size is detailed. In our experience, the use of a perforator propeller flap in the upper extremity for resurfacing represents both a very reliable and aesthetically pleasant option.

Reconstruction of complex back defects is challenging for reconstructive surgeons, as it should preserve function, provide adequate coverage, and minimize morbidity. We present a case of multiple-step reconstruction after resection of a large squamous cell carcinoma recurrence in a 68-year-old man, with local perforator flaps and a reverse-flow latissimus dorsi myocutaneous flap. After radical excision, four propeller perforator flaps were harvested to cover a 30 × 25 cm defect, based on the dorsal branch of the fifth posterior intercostal arteries (right 20 × 9 cm, left 17 × 9 cm) and on the superior gluteal arteries (right 20 × 11 cm, left 21 × 12 cm) bilaterally. In the second step, bilateral propeller perforator flaps based on the fourth lumbar arteries (right 18 × 13 cm, left 23 × 11 cm) were transposed to cover the residual loss of tissues. After 5 months, a recurrence occurred on the left midback. A wide en bloc excision of the last three ribs and pulmonary pleura was performed, and the synthetic mesh used for thoracic wall reconstruction was covered with an ipsilateral 20 × 10 cm reverse-flow latissimus dorsi myocutaneous flap based on the serratus anterior branch. All the flaps healed uneventfully and there were no donor-site complications. Two years postoperatively, the patient had a cosmetically acceptable result without any functional impairment. The reverse-flow latissimus dorsi myocutaneous flap can represent a salvage procedure in back complex defects reconstruction, especially when other local flaps have already been harvested in previous reconstructive procedures.

Mandibular reconstruction in skeletally immature patients is challenging for the Plastic Surgeon. Indeed, it requires replacement of the bony defect with restoration of the growth capability and joint function, when condyle is involved. Vascularized transfer of the proximal epiphysis of the fibula meets all these reconstructive requirements providing an adequate bone stock which also contains a growth plate and an articular surface. The purpose of this article is to report a case of mandibular reconstruction in a 13-year-old boy who underwent resection of a high-grade osteosarcoma involving mandibular angle, ramus, and condyle. A fibular free flap including proximal epiphysis, with its growth plate and the articular surface, was harvested based on the anterior tibial vessels. The fibular head articular surface was placed facing the articular fossa of the temporal bone. A reverse-flow end-to-end anastomosis was performed with the facial vessels. Postoperatively, no infection nor anastomosis complications occurred. Surgical sites healed uneventfully. At latest follow-up, 1 year after surgery, no signs of recurrence were observed. The transferred bone survived and the growth plate was clearly open. Both functional and aesthetic outcomes were rated as good, with maximal mouth opening of more than 4 cm, neither impairment to mastication, deglutition nor phonation was observed. This technique may be a good option for pediatric reconstruction of large bony and articular mandibular defects, where functional restoration of temporomandibular joint and the growing capacity of the bone should be contemporary.

Background: The posterior trunk has been considered a challenging area to reconstruct following soft tissue tumor excision because of the shortage of local donor sites. The advent of innovative procedures such as perforator flaps has radically changed this perspective and offered a new approach to the problem. Methods: Upon a review of the literature and the personal experiences of the senior author, an algorithm is developed according to the most updated procedure, combined with more conventional options that maintain a role in decision-making. Results: The upper back latissimus dorsi and trapezium flap are still the most reliable approaches, while perforator flaps based either on the circumflex scapular arteries or the transverse cervical artery represent a more refined option. In the middle third, few indications remain for the reverse latissimus dorsi, while the gold standard is represented by local perforator flaps based on the posterior intercostal system. In the lower back, conventional VY advancement flaps are still a safe and effective option in the sacral area, and perforator flaps based on posterior intercostal arteries, lumbar arteries and superior gluteal arteries are the first choice in most cases. Conclusions: Using perforator flaps significantly improved soft tissue reconstruction in the posterior trunk.

Background Intraneural ganglia are benign mucinous cystic formations that originate within the epineurium of peripheral nerves. Different treatments have been recommended, with an overall satisfactory outcome. In this paper, we aim to evaluate the long-term outcomes of surgical treatment of peroneal intraneural ganglia by reviewing our local institutional experience. Methods We performed a case series review of peroneal intraneural ganglia surgical treatment performed by the senior author. Demographic and surgical details were abstracted from the medical record for each patient. Electrodiagnostic studies and magnetic resonance imaging (MRI) were performed in all patients pre- and postoperatively. Results Eight men were enrolled, with an average age at time of surgery of 47.5 years (range 28–68 years). Motor testing revealed a preoperative deficit of dorsiflexion, eversion, and toe extension in 7 patients, with a median preoperative Medical Research Council (MRC) score of 0/5. Sensory loss in the distribution of the common peroneal nerve was present in 7 patients. Mean clinical follow-up time was 113 months (range 32–189 months). Significant pain relief was achieved in all patients. Overall neurologic function was improved, more so for motor function. The median postoperative dorsiflexion, eversion, and toe extension at last follow-up were MRC score of 5/5. No complications occurred postoperatively. There was no clinical evidence of intraneural recurrence, as confirmed in postoperative MRI. In 2 patients, an extraneural cystic formation was visible in the anterior muscular compartment. Conclusions The data from our series support excellent long-term postoperative motor outcomes with a low recurrence rate. To avoid extraneural recurrence, resection of the superior tibiofibular joint is necessary.

Background The submental artery island flap is widely used in head and neck reconstruction, since it is easy and quick to harvest, and it can be successfully used for the coverage of perioral, intraoral and facial defects. We used this technique for the reconstruction of a complex soft-tissue and bony defect of rhino-oropharinx. Case report Osteoradionecrosis of rhino-oropharingeal posterior wall with C2 necrotic body exposure occurred in a 77-year-old woman. After the failure of reconstruction with a Hadad-Bassagasteguy flap, a submental island flap with cervical spine stabilization was planned to be performed in a one-stage operation. The anterior arc of C1 and odontoid process of C2 were removed and, according to the defect size, a submental island flap was designed in an elliptical fashion. The flap was rotated 180° and tunnelized under the left parapharingeal-prevertebral space, then it was positioned in the rhino-oropharinx and fixed with reabsorbable sutures. The donor site was closed primarily. No peri- or post-operative complications occurred, neither in the recipient nor in the donor-site. At the latest follow-up, 15 months postoperatively, the patient was able to speak without any impairment and started swallowing rehabilitation with good results and an aesthetically satisfactory outcome. Conclusion The submental island flap may be a reliable and versatile flap for reconstruction of head and neck defects, even though in the rhino-oropharingeal posterior wall.

BACKGROUND Reconstruction of complex head and neck defects is challenging, especially when more than one soft-tissue subunit is involved. The osteocutaneous fibular flap underwent continual evolution to improve its soft-tissue characteristics, such as including a second skin island. The purpose of this study was to evaluate outcomes regarding oromandibular reconstruction with a double-skin paddle fibular free flap (DSPFFF) using three different techniques: central de-epithelialized skin paddle, distally-based double-skin paddle (DSP), or proximally and distally-based DSP. METHODS A systematic review was performed in December 2020 using Pubmed and MedLine Ovid databases according to the PRISMA guidelines. A meta-analysis of functional outcome and complications was performed to estimate single incidence rates. RESULTS A total of 449 patients were included, with a follow-up of 1-84 months, where 330 patients underwent reconstruction with the first technique, 23 patients with the second technique, and 96 patients with the third technique. The meta-analysis showed an overall good functional outcome and a low-complication rate for oromandibular reconstruction with DSPFFF. A better functional outcome and a lower complication rate were found when a distally-based DSPFFF was harvested compared to a proximally and distally-based DSPFFF. CONCLUSION The DSPFFF was found to be useful and reliable for reconstructing composite and extensive head and neck defects, with an overall good functional outcome and a low-complication rate. The meta-analysis showed a better positive outcome on distally-based DSPFFF rather than proximally and distally-based DSPFFF. In addition, distally-based DSPFFF showed a lower complications rate when compared with proximally and distally-based DSPFFF.

Reconstruction of foot structures is challenging because of the need to restore both anatomy and function. Extensor hallucis longus (EHL) excision without reconstruction could result in a flexion deformity of the toe at the interphalangeal joint. In this report, we present a case of the use of a palmaris longus tendon included in a fasciocutaneous radial forearm free flap to reconstruct EHL tendon and soft tissues of the distal foot dorsum. A 41-year-old woman presented with a recurrence of myxoinflammatory fibroblastic sarcoma on the medial part of the left foot dorsum. The EHL tendon was sacrificed, leaving a soft-tissue defect of 14 × 5 cm and 14-cm tendon gap. A 14 × 5 cm radial forearm flap with a 16-cm section of palmaris longus tendon was harvested from the left forearm. Radial artery and its comitant vein were anastomosed with dorsalis pedis artery and vein. EHL tendon repair was performed from the composite mass to the proximal and distal stumps. No complication in the postoperative period occurred. At latest follow-up, 12 months postoperatively, the patient showed a normal joint function and was satisfied with the treatment. Palmaris longus tendon included in a radial forearm free flap could be recommended for combined soft tissue and tendon defects, particularly on the foot dorsum.

Surgical reconstruction after humeral resection represents a challenging issue in orthopaedic oncology. Particularly in paediatric patients, the main concerns are maintaining limb function and reconstruction longevity. We describe a novel strategy of humeral reconstruction based on the use of a three-dimensional-printed custom-made prosthesis in a 13-year-old patient diagnosed with osteosarcoma. The implant was specifically designed to sustain the native head, which was spared, as it was not involved by the neoplastic tissue. The mechanical support the prosthesis provided was associated with the biological stimulus of a free vascularised fibular graft to obtain an anatomic, functional and stable construct. This solution has had good longevity, and after 3 years of follow-up, the patient still shows excellent limb function and personal satisfaction.

Background The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient population. The authors present their series of pediatric patients who underwent surgery using a medial femoral condyle free flap or a variant thereof in skeletal reconstruction and demonstrate the efficacy of this technique in this population. Methods A multi-institutional retrospective review of patients aged 18 years or younger who required a medial femoral condyle flap for skeletal reconstruction was undertaken. Operative technique, radiographs, and clinical outcomes were recorded. A novel technique (Innocenti) was used to avoid the distal femoral physis in which a Kirschner wire was placed under fluoroscopic guidance just proximal to the growth plate. Results Thirteen patients met inclusion criteria, with an average age of 14.7 years (range, 7 to 18 years) and mean follow-up of 28 months (range, 3 to 120 months). Six were skeletally immature at the time of medial femoral condyle harvest, with the last patient having organic bone disease, putting her at risk for pathologic fracture. All 13 patients achieved bony union, and no patients suffered pathologic fractures or physeal injuries; no patients developed length discrepancies. Conclusions The authors present the first series of corticocancellous medial femoral condyle free flaps in the pediatric population along with a novel technique to avoid injury to the physis in skeletally immature patients. This technique is effective for a variety of skeletal defects or nonunions and is safe for growing patients without causing physeal arrest or growth disturbance. Clinical question/level of evidence Therapeutic, IV.

Recently, custom-made 3D-printed prostheses have been introduced for limb salvage surgery in adult patients, but their use has not been described in pediatric patients. A series of 11 pediatric patients (mean age 10.8 years, range 2–13) with skeletal tumors treated with custom-made implants for the reconstruction of bony defects is described. Patients were followed up every 3 months. Functional results were evaluated by the Musculoskeletal Tumor Society Score (MSTS) for upper and lower limbs. The mean follow-up was 25.7 months (range 14–44). Three patients died after a mean of 19.3 months postoperatively—two because of disease progression and the other from a previous malignancy. Three patients experienced complications related to soft tissues. One patient required device removal, debridement, and antibiotic pearls for postoperative infection. Partial osseointegration between grafts and host bone was observed within a mean of 4 months. At the final follow-up, mean MSTS score was 75%. 3D prostheses may yield biological advantages due to possible integration with the host bone and also through the use of vascularized flaps. Further research is warranted.

Summary The updated knowledge of perforasome anatomy and the evolution of microsurgical techniques have enabled surgeons to safely harvest a thin flap. Recently, the anterolateral thigh perforator flap, the current workhorse in soft-tissue reconstruction, has started to be designed and harvested on the superficial fascia, which divides the deep from the superficial fat. This allows elevation of a very thin flap tailored to the defect. Faithful to the ultrathin concept, in an attempt to make flap dissection simpler and safer, the authors describe a revisited harvesting technique of superthin anterolateral thigh perforator flap. This study presents the outlined technique performed in 16 patients with complex soft-tissue defects after trauma or tumor ablation. All of them underwent primary reconstruction using superthin anterolateral thigh perforator free flaps by superficial fascia elevation harvested according to the described surgical procedure. Complications and functional outcomes were assessed. The authors' series of anterolateral thigh perforator superthin flaps demonstrated an overall 100 percent survival rate. Of 16 anterolateral thigh perforators, 12 (75 percent) had no complications and four (25 percent) had minor complications. No major complications such as total flap loss requiring additional salvage surgery were reported. In no case was secondary debulking performed. The superthin anterolateral thigh perforator flap harvested with the described approach was used successfully in microsurgical reconstruction, providing an excellent outer skin cover tailored to the defect. The dissection procedure was safe, quick, simple, and free of major complications. With minimal donor- and recipient-site morbidity, it provided great aesthetic results, avoiding secondary operations. Clinical question/level of evidence Therapeutic, IV.

Introduction: Mandibular defects reconstruction could result challenging in childhood, due to facial and mandibular growth patterns. For these reasons, the choice of the most suitable reconstructive option in pediatric patients, affected by mandibular malignancies, still objects of debate. Objective: The aim of our study was to compare our reconstructive schedules to the existing literature in order to give a personal contribute to the present panorama. Methods: We performed, in October 2019, a retrospective evaluation of pediatric patients treated for biopsy-proven mandibular malignancies at our Institute between January 2013 and December 2016. All of them received multimodal therapy in accordance with standard guidelines and their demographic, clinical, treatment, and outcome parameters were collected and analyzed. Results: We observed a shorter duration of surgery, a faster tracheostomy tube and feeding-tube removal, and a minor hospitalization in patients who received grafts transfer compared to those who underwent microsurgical mandibular reconstruction. After a 36-month period of follow-up, osteochondral grafts showed a pattern of growth similar to the mandibular epiphysis (condilylion-gonion linear and vertical ratio ranging to 0.96–1.03 and 1–1.02 at orthopantomogram, respectively). No bone consolidation delays and functional impairment were recorded. Conclusions: Free flaps mandibular reconstruction in children needs to be better assessed and proximal fibular epiphyseal free flap indication might deserve further studies. Osteochondral grafts find indication for lateral defects, 50–55 mm in maximum length and located in the mandibular ramus, without massive teeth or soft tissue defect. Condyle involvement does not represent an absolute contraindication to rib graft use.

While robotics has primarily penetrated laparoscopic surgery with the product offering of Intuitive Surgical and to a lesser extent orthopedic, spinal, and brain surgery, plastic surgery has remained largely untouched by robotics to date, partially due to the absence of a dedicated robotic technology. In this chapter, we examine the technology gaps that have contributed to this scenario and describe how the resulting criteria for a robotic platform for reconstructive microsurgery have propelled an end-user-driven development of a robotic platform with wristed robotic microinstruments for open surgery.