Within the last 20 years, robotic-assisted surgeries have been implemented as routine procedures in many surgical fields, except in plastic surgery. Although several case series report promising results, technical and economic aspects have prevented its translation into clinical routine. This review is based on a PubMed and Google Scholar database search, including case reports, case series, clinical and preclinical trials, as well as patents. Past, recent approaches, ongoing patents, as well as eight specific systems for robotic-assisted microsurgery and their potential to be translated into a clinical routine, are described. They may lay the ground for a novel field within plastic surgery. This review provides an overview of the emerging technologies and clinical and preclinical studies and discusses the potential of robotic assistance in the field of plastic surgery.

Lipedema patients suffer not only from visual stigma but also reduction in their quality of life through pain and performance loss in daily life. In clinical practice, it is still difficult to reliably diagnose the disease. This study aims to provide further insights into the characteristics of lipedema patients of all stages and provide a baseline prior to surgery for a surgical treatment evaluation by means of patient-reported outcome measures. Methods: Patients completed a lipedema-specific questionnaire containing 50 items, the World Health Organization Quality of Life BREF (WHOQOL-BREF) and the Patient Health Questionnaire 9 (PHQ-9). The data were analyzed using SPSS statistics 27. Patients who had already received liposuction were excluded. Results: Five hundred and eleven patients were included, of whom 337 completed the PHQ9 and 333 completed the WHOQOL-BREF questionnaires. The general characteristics of lipedema patients, especially the daily symptoms, are described. Previous observations, such as the frequent occurrence of hypothyroidism and the low rate of type 2 diabetes, were confirmed. Over 49% suffer from severe impairments in their jobs, whereby the disease shows a familial accumulation. The results of the WHOQOL-BREF and the PHQ-9 suggest a high level of mental stress. Discussion: As surgical intervention in lipedema patients is gaining traction, its effects should be well-documented. Therefore, a comprehensive baseline needs to be established prior to surgical treatment. The psychological components are just as important as the inclusion of daily impairments.

Background: Recent advancements in the development of robotic devices increasingly draw the attention toward the concept of robotic microsurgery, as several systems tailored to open microsurgery are being introduced. This study describes the combined application of a novel microsurgical robot, the Symani, with a novel robotic microscope, the RoboticScope, for the performance of microvascular anastomoses in a two-center preclinical trial. Methods: Six novices, residents, and experienced microsurgeons (n = 18) performed five anastomoses on 1.0-mm-diameter silicone vessels with a conventional versus combined robotic approach, resulting in 180 anastomoses. Microsurgical performance was evaluated, analyzing surgical time, subjective satisfaction with the anastomosis and robotic setup, anastomosis quality using the anastomosis lapse index score, microsurgical skills using the Structured Assessment of Microsurgery Skills score, and surgical ergonomics using the Rapid Entire Body Assessment score. Results: All participants significantly improved their performance during the trial and quickly adapted to the novel systems. Surgical time significantly decreased, whereas satisfaction with the anastomosis and setup improved over time. The use of robotic systems was associated with fewer microsurgical errors and enhanced anastomosis quality. Especially novices demonstrated accelerated skill acquisition upon robotic assistance compared with conventional microsurgery. Moreover, upper extremity positioning was significantly improved. Overall, the robotic approach was subjectively preferred by participants. Conclusions: The concept of robotic microsurgery holds great potential to improve precision and ergonomics in microsurgery. This two-center trial provides promising evidence for a steep learning curve upon introduction of robotic microsurgery systems, suggesting further pursuit of their clinical integration.

This study provides a comprehensive guide to robotic-assisted microsurgery. Following more than 900 clinical cases in 13 centers, this joint project was initiated to summarize and consent to the user experience. Two robotic systems specifically designed for the needs of open microsurgery received the first certification for clinical application (CE mark) in 2019 and 2020. Since their introduction into clinical application, several European microsurgical centers have implemented these systems, generating user experiences in multiple microsurgical subspecialties. All institutions using the MUSA-2 microsurgical robot (Microsure B.V., Eindhoven, Netherlands) or Symani Surgical System (Medical Microinstruments, Inc., Wilmington, Delaware, US) were invited to join the multicenter project. A modified nominal group technique was applied to answer five major questions regarding current and future indications and developments in open robotic-assisted microsurgery. Steep preclinical and clinical learning curves were characterized. General considerations concerning the two different systems are presented. Specifics for each microsurgical subspecialty are reported. Following two voting rounds, a consensus was reached in three of the five major questions with “lymphatics” being the top indication, “higher precision” being the top benefit, and “automation” being the top long-term goal of robotic-assisted microsurgery. This joint project of all Symani and MUSA-2 users presents clinical cases and the subsequent initial knowledge and experience. Lymphatics as a top indicator and a higher precision as the top benefit point toward the capabilities of robotic-assisted microsurgery in manipulation of smallest structures. Automation may further enhance and simplify robotic procedures in future. This project also provides a comprehensive guide to any institution aiming to introduce such a system for open robotic-assisted microsurgery in future.

Chronic rejection remains the Achilles heel in vascularized composite allotransplantation. Animal models to specifically study chronic rejection in vascularized composite allotransplantation do not exist so far. However, there are established rat models to study chronic rejection in solid organ transplantation such as allogeneic transplantation between the rat strains Lewis and Fischer344. Thus, we initiated this study to investigate the applicability of hindlimb transplantation between these strains to imitate chronic rejection in vascularized composite allotransplantation and identify potential markers. Allogeneic hindlimb transplantation were performed between Lewis (recipient) and Fischer344 (donor) rats with either constant immunosuppression or a high dose immunosuppressive bolus only in case of acute skin rejections. Histology, immunohistochemistry, microarray and qPCR analysis were used to detect changes in skin and muscle at postoperative day 100. We were able to demonstrate significant intimal proliferation, infiltration of CD68 and CD4 positive cells, up-regulation of inflammatory cytokines and initiation of muscular fibrosis in the chronic rejection group. Microarray analysis and subsequent qPCR identified CXC ligands 9–11 as potential markers of chronic rejection. The Fischer344 to Lewis hindlimb transplantation model may represent a new option to study chronic rejection in vascularized composite allotransplantation in an experimental setting. CXC ligands 9–11 deserve further research to investigate their role as chronic rejection markers.

Background: Lipedema, as a disabling and consequential disease, is gaining more awareness due to its potential omnipresence. Patients suffering from lipedema show a characteristic painful display of symmetric accumulations of adipose tissue. The combination of swelling, pain and decreased quality of life (QOL) is outstanding for the diagnosis. The aim of this study was to identify the effect of liposuction in terms of the QOL for patients and underline important factors of current and pending research regarding surgical therapy of lipoedema. Methods: Patients suffering from lipedema prior to and after receiving liposuction at our hospital were included in this study. Patients completed a lipedema-specific self-designed 50 item questionnaire: the World Health Organization Quality of Life BREF (WHOQOL-BREF) and the Patient Health Questionnaire 9 (PHQ-9). A linear mixed model was used for outcome analysis. Results: In total, 511 patients completed a questionnaire prior to the surgery at primary presentation to the hospital and a total number of 56 patients completed a questionnaire after liposuction. A total of 34 of these patients filled in both questionnaires prior to and after surgery. The general characteristics of the disease, such as daily symptoms and psychological health, pertinently improved after surgery. Conclusions: Liposuction can have a general improving effect on the QOL of patients, both in private and professional life. Liposuction may currently be the most evident and promising method in the treatment of lipedema.