Conventional pedicled flaps for soft tissue reconstruction of lower extremities have shortcomings, including donor-site morbidity, restricted arc of rotation, and poor cosmetic results. Propeller flaps offer several potential advantages, including no need for microvascular anastomosis and low impact on donor sites, but their drawbacks have not been fully characterized. We assessed (1) frequency and types of complications after perforator-based propeller flap reconstruction in the lower extremity and (2) association of complications with arc of rotation, flap dimensions, and other potential risk factors. From 2007 to 2012, 74 patients (44 males, 30 females), 14 to 87 years old, underwent soft tissue reconstruction of the lower extremities with propeller flaps. General indications for this flap were wounds and small- and medium-sized defects located in distal areas of the lower extremity, not suitable for coverage with myocutaneous or muscle pedicled flaps. This group represented 26% (74 of 283) of patients treated with vascularized coverage procedures for soft tissue defects in the lower limb during the study period. Minimum followup was 1 year (mean, 3 years; range, 1–7 years); eight patients (11%) were lost to followup before 1 year. Complications and potential risk factors, including arc of rotation, flap dimensions, age, sex, defect etiology, smoking, diabetes, and peripheral vascular disease, were recorded based on chart review. Twenty-eight of 66 flaps (42%) had complications. Venous congestion (11 of 66, 17%) and superficial necrosis (seven of 66, 11%) occurred most frequently. Eighteen of the 28 complications (64%) healed with no further treatment; eight patients (29%) underwent skin grafting, and one patient each experienced total flap failure (2%) and partial flap failure (2%). In those patients, a free anterolateral thigh flap was used as the salvage procedure. No correlations were found between complications and any potential risk factor. We were not able to identify any specific risk factors related to complications, and future multicenter studies will be necessary to determine which patients or wounds are at risk of complications. Propeller flaps had a low failure rate and risk of secondary surgery. These flaps are particularly useful for covering small- and medium-sized defects in the distal leg and Achilles tendon region and are a reliable and effective alternative to free flaps. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Sarcomas that arise from the scapula or periscapular soft tissues often require a total scapulectomy. This often implies a large complex tissue defect that needs adequate reconstruction of both bone and soft tissue. Although various methods have been developed, no optimal procedure has emerged. Postoperative complications are common and functional recovery is not always satisfactory. This study aims to present a new surgical technique that combines a custom-made scapular prosthesis with a functional latissimus dorsi flap. Two patients diagnosed with malignant tumour of the scapular region were surgically treated after proper multidisciplinary evaluation. The first patient underwent the procedure as a first surgery, the second as revision surgery. The new technique comprises three surgical stages: excisional surgery with soft tissue resection and scapulectomy, bone reconstruction with custom-made prosthesis, and soft tissue reconstruction using a latissimus dorsi rotational flap overturned on the prosthesis. The goal is to set up a new functional unit combining an anatomically shaped implant (manufactured using latest three-dimensional printing technology) and a muscular flap, and to maintain the neurovascular supply. The patients were followed up to evaluate functional outcome and complications. Both patients were alive with no evidence of disease. Functional results were satisfactory and the Musculoskeletal Tumor Society scores were 87% and 63%, respectively. No surgical complications such as implant breakage, joint collapse, wound dehiscence, or infection were observed. This new technique upgrades the role of the latissimus dorsi flap to a functional tool in combination with an anatomical, three-dimensionally printed, custom-made prosthesis, and provides adequate well-vascularized and healthy tissue to maximize the likelihood of successful limb salvage.

Today, robotics has become the gold standard in the operating room for several procedures and surgical specialties. However, microsurgery has not been touched to date other than the limited application of the da Vinci Surgical System, not focused on microanastomosis. Differently from da Vinci, which aims to facilitate minimally invasive procedures by providing improved vision and dexterity to the conventional laparoscopic approach, new microsurgical robots are now designed and being introduced to provide improved precision for anastomosis. Thanks to elimination of tremor and high scaling potential, robotics in microsurgery probably will acquire increasing value as the current trend in submillimetric anastomosis will be confirmed in the clinical practice. Currently, two dedicated robots for microsurgery have been developed: MUSA by Microsure and Symani by MMI ([Fig. 1]). These platforms aim to increase surgeon's precision allowing for fine manipulation of very small anatomy in open surgery, rather than decrease invasiveness. Although in its infancy, robotic microsurgery already has a small body of primary literature. A pilot study in lymphovenous anastomosis (LVA) using the MUSA system[1] has been recently published and a paper reporting the first human case of robotic-assisted free flap with Symani is currently in press in Plastic and Reconstructive Surgery. A comprehensive review of the potential of robotic microsurgery has recently been published in the book Robotics in Plastic and Reconstructive Surgery by Springer,[2] indicating that this subspecialty might be “here to stay.” The Symani Surgical System saw its first clinical use in Careggi University Hospital in Florence, Italy, where both the first free flaps and LVA procedures were done.[3] This year, two more Symani Surgical Systems have been installed in Europe and are in use in the fields of plastic surgery and maxillofacial surgery at the University of Zurich and Salzburg, respectively. Our personal experience in Florence is limited to 15 cases. These include bone flaps, soft tissue flaps including perforator-to-perforator, and three cases of LVA for lymphedema, with encouraging results. Particularly in supermicrosurgery the absence of tremor significantly increases the precision in the passage of the needle and the overall accuracy of the procedure with minimal effort by the surgeon. However, like other innovative procedures, robotic microsurgery needs to be further refined and validated on a larger scale. A multicenter postmarket clinical study has been initiated at Careggi University Hospital to provide a tool to analyze a homogeneous series of data and identify the areas of highest clinical benefit. Most of the progress in reconstructive microsurgery over the past 30 years is substantially sustained by a tremendous improvement in the knowledge of vascular anatomy, at a size neglected by conventional anatomy. The most innovative procedures today, such as perforator flaps, propeller flaps, ultrathin flaps, lymph node transfers, and LVA, are enabled by this new vascular awareness that has come to fruition.[1] [2] [3] Most of these new procedures push the surgeon beyond the average manual dexterity to enter the world of supermicrosurgery. In analogy with the operative microscope which allowed the healthy and trained eyes of the surgeons to reach magnification to an extent not replicable by the human eye, the microsurgical robot will make feasible for the average microsurgeon to execute microsutures beyond natural dexterity. Although it is unlikely that a robotic arm will replace the human hand in the near future, robotic microsurgery in my opinion is the most powerful technological innovation in reconstructive microsurgery in the past 20 years and is a promising field of application for the next generation plastic surgeons. Article published online: 27 May 2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

Background: Painful conditions such as residual limb pain (RLP) and phantom limb pain (PLP) can manifest after amputation. The mechanisms underlying such postamputation pains are diverse and should be addressed accordingly. Different surgical treatment methods have shown potential for alleviating RLP due to neuroma formation — commonly known as neuroma pain — and to a lesser degree PLP. Two reconstructive surgical interventions, namely targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), are gaining popularity in postamputation 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 an international, double-blind, RCT to assess the effectiveness of TMR, RPNI, and a non-reconstructive procedure called neuroma transposition (active control) in alleviating RLP, neuroma pain, and PLP. Methods: One hundred ten upper and lower limb amputees suffering from RLP will be recruited and assigned randomly to one of the surgical interventions (TMR, RPNI, or neuroma transposition) in an equal allocation ratio. Complete evaluations will be performed during a baseline period prior to the surgical intervention, and follow-ups will be conducted in short term (1, 3, 6, and 12 months post-surgery) and in long term (2 and 4 years post-surgery). After the 12-month follow-up, the study will be unblinded for the evaluator and the participants. If the participant is unsatisfied with the outcome of the treatment at that time, further treatment including one of the other procedures will be discussed in consultation with the clinical investigator at that site. 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 different pain evaluation methods known to have clinical relevance. We plan to analyse the primary variable, mean change in NRS (0–10) between baseline and the 12-month follow-up, using the intention-to-treat (ITT) approach to minimise bias and keep the advantage of randomisation. The secondary outcomes will be analysed on both ITT and per-protocol (PP). An adherence protocol (PP population) analysis will be used for estimating a more realistic effect of treatment. Trial registration: ClinicalTrials.gov NCT05009394.