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(1)
©The Author(s), under exclusive license to Springer Nature Switzerland AG2023
E. Tokgöz, M. A. Carro, Cosmetic and Reconstructive Facial Plastic Surgery
https://doi.org/10.1007/978-3-031-31168-0_6
Future Directions for Surgical
Advancements
MarinaA.Carro
1
The Frank H. Netter M.D. School of Medicine, Quinnipiac University,
North Haven, CT, USA
MarinaA.Carro
Email: Marina.Carro@quinnipiac.edu
Keywords Robotic surgery and current role in plastic surgery – Use of
technological advancements and hesitancy in plastic reconstructive surgery
– Technological advancements in surgical training – Costs of robotic
surgery and related equipment – Feasibility of applied technological
advancements in plastic reconstructive surgery – Credentialing for robotic
assisted surgery – Future directions of technological optimization –
Technological optimizations and provider perspective – Barriers to
widespread use of technological advancements
Marina A. Carro is a second-year medical student at the Frank H. Netter
School of Medicine (Quinnipiac University). Prior to medical school, she
worked as a project manager at Clínica Esperanza Hope Clinic in
Providence, Rhode Island, where she organized and managed a satellite
COVID-19 vaccination clinic for underserved populations in the area.
Additionally, she has worked as a certified nursing assistant for 3years in
the emergency department and intensive care unit at South County Hospital
in Kingston, Rhode Island. Currently, she is on the board for the Frank H.
Netter Wellness Committee, ENT Surgical Interest Group, and American
Medical Student Association at Netter. She hopes to continue exploring her
interests in clinical procedural research, healthcare business and
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administration, and provide equitable healthcare for marginalized patients
throughout the rest of her career.
1 Introduction
The field of plastic and reconstructive surgery is rapidly growing, as the
intersection of medicine and technology is continuously developing and
expanding. Surgical reconstruction may be improved by the use of threedimensional CT, lending to increased accuracy with preoperative
measuring, modeling, surgical reconstruction guides, and prefabricated
implants [1–4]. Recent advancements in artificial intelligence (AI) and
plastic surgery are beginning to pave the way for improved patient
assessment, three-dimensional surgical planning, and intraoperative
navigation [5]. Initial concerns for AI applications are centered on data
security [6], maintenance of diverse racial features after cosmetic surgery
[7], and autonomous robotic capability in complex surgical procedures [8].
Despite these concerns, there have been promising studies showing
improved intraoperative imaging and decision-making using robotic
surgical systems, in which a camera is used to identify anatomical structures
and determine the stage of a procedure [9]. In addition, AI is shown to be
useful in the assessment of burns when combined with spectrophotometric
analysis, providing additional insight for reconstructive surgeons [10].
Additional developments are discussed here, along with current user
perspectives and expected future applications. The structure of the
outcomes we present in this work is similar to those presented in [29, 33,
43–77].
2 Discussion of Current Surgical Advancements
Newer technology has been developed to improve the education of surgical
residents and attending surgeons, reconstruct defects with improved
accuracy and outcomes, and make significant aesthetic changes with
minimally invasive surgical and non-surgical procedures. Some of these
developments are in use today, while others are taking longer to become
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compatible with the intricacies and required aesthetic perspective of plastic
and reconstructive surgery.
Virtual surgical simulators use interactive computer software, providing
residents and surgeons with anatomically accurate surgical fields and
haptic/tactile feedback during surgical simulation modules. These are
shown to be more effective than textbooks when used for training purposes
[11, 12], and can be applied to orthognathic and maxillofacial surgery, cleft
lip repair, skin flap repair, and orbital floor/bone reconstruction [13–17].
While these techniques cannot replace practice in real-time with live
patients, they are well-utilized in preparing surgeons and residents for the
use of advanced technology in the operating room [18] (Fig. 1).
Fig. 1 Image A (left) shows a screenshot of Touch Surgery’s “learn mode,” in which surgical
trainees practice required techniques with haptic feedback. On the right, Image B shows “test mode,”
which allows trainees to assess the previously learned skills [15]
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Surgical planning is another area which has been shown to benefit from
virtual software developments, now referred to as Virtual Surgical Planning
(VSP) technology. Virtual reconstructive surgery is reviewed and followed
through the predicted course prior to real-time reconstruction, allowing
surgeons to determine the efficacy of their predetermined methods and
make necessary improvements. The patient’s relative anatomy is
determined with measurement of key landmarks from 3D patient imaging.
Once these landmarks are located and marked, they can be used as input
values for surgical planning to create the virtual environment (i.e., the
patient’s body).
Mimics software (Mimics 17.0, Materialize NV, Leuven, Belgium) is
one of the technologies utilized in VSP, in conjunction with pre-planned
design of titanium plates for implantation. Its efficacy in the repair of
complex midfacial fractures has been assessed, and this technology has
been shown to reduce intraoperative time and complications [24] (Fig. 2).
Fig. 2 Colored images show the sequential VSP (a, b, f) and its applications for creation of custom
implants using Rhino 6 software technology (Robert McNeel & Assoc.; Seattle, USA) (d, e, h, i) for
individualized repair of maxillary trauma. The black dotted lines highlight the creation of customized
slots to guide implant placement (c, g) [25]
The use of 3D and now 4D image manipulation with recently developed
software is discussed in detail within the next chapter, as well as the
available software options for purchase. Using optimal 3D surface imaging,
the patient’s face can be accurately reproduced in a digital format, and
postoperative results may be simulated prior to surgery. This visual display
allows surgeons to provide patients and surgeons with more detailed
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preoperative guidance and may provide both individuals with increased
satisfaction after the operation [29].
Computer-aided design (CAD) of custom implants using detailed
patient imaging (3D CT, MRI, cone-beam CT) has been well documented
in the literature and is shown to benefit patient outcomes, accuracy, and
surgical efficiency. 3D-printed implants have been used most frequently in
mandibular reconstruction after traumatic injury, osteonecrosis, or tumor
removal, in addition to orbital and temporomandibular joint reconstruction
[19]. Segmental mirroring is another technique in which the unaffected
contralateral structure is digitally replicated and used to design a custom
reconstruction plate. Its accuracy has been evaluated using 3D conformance
comparisons, and it shows promising potential in optimizing aesthetic and
functional postoperative outcomes in mandibular fracture repair [29, 30].
While older technologies have only allowed for use of titanium and/or
materials which can tolerate the mechanical processes of printing, newer
printers such as 3D-Bioplotters (EnvisionTEC GmbH) can create custom
scaffolds using viable cells and/or hydrogels to create bone or soft tissues
[20, 21]. Challenges with tissue implants are centered on rapid
vascularization after transplantation, although Kolesky et al. have
developed a custom-made bioprinter to allow for incorporation of multiple
cell types and improved vascularization with endothelial cell-lined channels
[22]. Tissue-engineered constructs are rapidly being developed, with
advances in the creation of muscle, bone, adipose, cartilage, and skin
scaffolds. The use of bioreactors (cell serum supplementations) with 3Dprinted materials have allowed for improved differentiation and
proliferation [23].
Advancements in robotics led to the development of the PUMA 200 in
1985 as the first “robot surgeon.” Shortly after, the “master-slave” robot
concept was developed in the 1990s, allowing for remote manipulation of
robotic attachments from a surgical workstation [32]. In the field of plastic
and reconstructive surgery, robotic technology is used in surgeries today
including follicular unit extraction (ARTAS robotic system) and radial
forearm free-flap craniofacial reconstruction. Additional robotic
advancements in this field are further discussed in chapter “Robotics
Applications in Facial Plastic Surgeries” [33] (Fig. 3).
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