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(1)
©The Author(s), under exclusive license to Springer Nature Switzerland AG2023 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
MarinaA.Carro
1
The Frank H. Netter M.D. School of Medicine, Quinnipiac University, North Haven, CT, USA
MarinaA.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 3years 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 [14]. 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,
4377].
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 [1317]. 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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