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Microsurgery: Current and Future Challenges
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Microsurgery: Current and Future Challenges

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Plastic, Reconstructive and Aesthetic Surgery/Aesthetic Medicine".

Deadline for manuscript submissions: 20 January 2026 | Viewed by 3896

Special Issue Editor

Dr. Matthias Aitzetmüller-Klietz

E-Mail Website
Guest Editor
1. Department of Plastic Surgery, University Hospital Muenster, 48149 Muenster, Germany
2. Department for Plastic, Aesthetic, Hand- and Reconstructive Surgery, Klinikum Passau, University Campus Lower Bavaria, 94032 Passau, Germany
Interests: breast surgery; breast reconstruction; facial plastic surgery
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Currently, no subfield in plastic surgery is undergoing as many changes as the field of microsurgery. Technical innovations have driven and allowed for a surgical evolution with novel treatment options and simultaneous improvement of outcome.

Innovations such as robotic-assisted microsurgery or Artificial Intelligence, have the potential to change the whole field of microsurgery. But when transferring from bench to bedside, all of these innovations are facing the same obstacles: initially prolonged surgery time, concerns regarding patient safety, high costs or problems in patient selection- just to mention some of them. Some innovations are overcoming these hurdles, but many are failing to make the step into everyday clinical practice.

This Special Issue focuses on challenges in microsurgery—because it is not about having a solution and creating a problem, but about having a problem and finding a solution.

We are looking forward to receiving papers about your problems and solutions in microsurgery.

Dr. Matthias Aitzetmüller-Klietz
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • microsurgery
  • reconstruction
  • reconstructive surgery
  • breast reconstruction
  • extremity reconstruction

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Published Papers (5 papers)

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Research

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12 pages, 2144 KB  
Article
Microvascular ALT-Flap Reconstruction for Distal Forearm and Hand Defects: Outcomes and Single-Case Application of a Bone-Anchored Venous Anastomosis
by Adrian Matthias Vater, Matthias Michael Aitzetmüller-Klietz, Philipp Edmund Lamby, Julia Stanger, Rainer Meffert, Karsten Schmidt, Michael Georg Jakubietz and Rafael Gregor Jakubietz
J. Clin. Med. 2025, 14(19), 6807; https://doi.org/10.3390/jcm14196807 - 26 Sep 2025
Viewed by 428
Abstract
Background: Reconstruction of distal forearm and hand soft tissue defects remains a complex surgical challenge due to the functional and aesthetic significance of the region. Several flap options have been established such as the posterior interosseous artery flap (PIA) or temporalis fascia flap [...] Read more.
Background: Reconstruction of distal forearm and hand soft tissue defects remains a complex surgical challenge due to the functional and aesthetic significance of the region. Several flap options have been established such as the posterior interosseous artery flap (PIA) or temporalis fascia flap (TFF), yet the anterolateral thigh flap (ALT) has gained increasing attention for its versatility and favorable risk profile. Methods: We retrospectively analyzed 12 patients (7 males, 5 females; mean age 51.8 years) who underwent free microvascular ALT reconstruction for distal forearm and hand defects between May 2020 and May 2025. Etiologies included infection, chemical burns, explosion injuries, and traffic accidents. The mean defect size was 75.4 cm2, and the average operative time was 217 min. Secondary flap thinning was performed in eight cases. In one patient without available recipient veins, a pedicle vein was anastomosed using a coupler device anchored into a cortical window of the distal radius to establish venous outflow via the bone marrow. Results: All flaps demonstrated complete survival with successful integration. Minor complications included transient venous congestion in one case and superficial wound dehiscence in four cases. Functional outcomes were favorable, with postoperative hand function rated as very good in 10 of 12 patients at follow-up. The bone-anchored venous anastomosis provided effective venous drainage in the salvage case. Conclusions: The free microvascular ALT is a reliable and highly adaptable method for distal forearm and hand reconstruction. It provides excellent soft tissue coverage, allows for secondary contouring, and achieves both functional and aesthetic goals. Furthermore, intraosseous venous anastomosis using a coupler device might represent a novel adjunct that may expand reconstructive options in cases with absent or unusable recipient veins. Full article
(This article belongs to the Special Issue Microsurgery: Current and Future Challenges)
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11 pages, 3672 KB  
Article
Pelvic and Perineal Reconstruction After Bowel, Gynecological or Sacral Tumor Resection: A Case Series
by Aikaterini Bini and Spyridon Stavrianos
J. Clin. Med. 2025, 14(9), 3172; https://doi.org/10.3390/jcm14093172 - 3 May 2025
Viewed by 1221
Abstract
Background/Aim: Perineal, pelvic and urogenital reconstruction presents a challenge, not only due to defect size but also due to high morbidity resulting from surgery and post-operative complications. The purpose of this study is to review the surgical approach and evaluate the results regarding [...] Read more.
Background/Aim: Perineal, pelvic and urogenital reconstruction presents a challenge, not only due to defect size but also due to high morbidity resulting from surgery and post-operative complications. The purpose of this study is to review the surgical approach and evaluate the results regarding pelvic/perineal reconstruction after advanced tumor resection. Patients and Methods: The total number of patients was 34 (11 males, 23 females). The histology varied, including sixteen rectal-anal squamous cell carcinomas, five Buschke-Lowenstein tumors, four vulvar-vaginal carcinomas, four sacral chordomas, two cutaneous squamous cell carcinomas, two soft tissue sarcomas and a case of Paget’s disease. Most patients had previously been treated with colectomies and/or gynecological resections and received a full dose of radiotherapy. Reconstruction was performed with the following flaps: oblique/vertical rectus abdominis myocutaneous flap (ORAM/VRAM), gracilis myocutaneous flap, inferior gluteal artery perforator flap (IGAP), internal pudendal artery perforator flap (IPAP) and lotus petal flaps. Results: Most patients had a relatively uncomplicated post-operative course. Surgical site infection and wound dehiscence occurred more commonly with the thigh flaps rather than the abdominal flaps. However, the aggression and the frequent recurrences of these tumors had as a result, only 15 out of 34 patients achieved a five-year disease-free survival. Conclusions: Pelvic and perineal defects are usually massive and the use of myocutaneous flaps to eliminate the dead space is of paramount importance. Although these are mainly salvage operations with a low survival rate, they promote patients’ quality of life. A frequent challenge is the simultaneous achievement of tumor radical resection and pelvis functionality. Full article
(This article belongs to the Special Issue Microsurgery: Current and Future Challenges)
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9 pages, 2433 KB  
Article
Lessons Learned from Reconstructing Severe Hand Injuries During the COVID-19 Pandemic
by Christina Glisic, Tonatiuh Flores, Erol Konul, Hugo Sabitzer, Giovanni Bartellas, Alexander Rohrbacher, Berfin Sakar, Sascha Klee, Uwe Graichen, Patrick Platzer, Klaus F. Schrögendorfer and Konstantin Bergmeister
J. Clin. Med. 2025, 14(7), 2169; https://doi.org/10.3390/jcm14072169 - 22 Mar 2025
Viewed by 649
Abstract
Background: COVID-19 presented many challenges for our health system, one being a suspected change in the epidemiology of severe hand trauma modalities. These complex injuries are traditionally treated at specialized hand trauma centers, but COVID-19 has in many ways disturbed these established [...] Read more.
Background: COVID-19 presented many challenges for our health system, one being a suspected change in the epidemiology of severe hand trauma modalities. These complex injuries are traditionally treated at specialized hand trauma centers, but COVID-19 has in many ways disturbed these established pathways and presented new challenges. Methods: We retrospectively analyzed finger amputation injuries treated at the University Hospital of St. Poelten between 2018 and 2022 to examine differences in the management of micro amputation injuries before and during the COVID-19 pandemic. Further challenges in the treatment of hand trauma patients were analyzed and solutions were developed. Results: Overall, the number of occupational finger amputation injuries in Lower Austria declined during the COVID-19 pandemic. Contrarily, more private accidents were treated in the same period, suggesting a lockdown specific change in injury characteristics. Throughout the entire examined period, a total of 130 injured fingers, including 29 thumbs, were treated. In 67 cases, a reconstruction attempt was feasible and successful in 59 cases. Specific challenges were fewer active hand trauma centers, subsequent long transport times, specific COVID-19 prevention measures, and limited postoperative rehabilitation resources. Conclusions: Despite many challenges overall affecting the time to revascularization, good results were achieved by small but meaningful modifications. These included well-established principles such as back table preparation and strengthening novel concepts such as tele-medicine for patient selection. Overall, the reconstruction of severe hand injuries is often challenging, especially during a world-wide health crisis, but with adequate solutions, good results can be readily achieved. Full article
(This article belongs to the Special Issue Microsurgery: Current and Future Challenges)
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16 pages, 740 KB  
Systematic Review
Validated Microsurgical Training Programmes: A Systematic Review of the Current Literature
by Victor Esanu, Teona Z. Carciumaru, Alexandru Ilie-Ene, Alexandra I. Stoia, George Dindelegan, Clemens M. F. Dirven, Torstein Meling, Dalibor Vasilic and Victor Volovici
J. Clin. Med. 2025, 14(21), 7452; https://doi.org/10.3390/jcm14217452 - 22 Oct 2025
Viewed by 236
Abstract
Background: Microsurgical skill acquisition and development are complex processes, due to the often complex learning curve, limited training possibilities, and growing restrictions on working hours. Simulation-based training programmes, employing various models, have been proposed. Nevertheless, the extent to which these training programmes are [...] Read more.
Background: Microsurgical skill acquisition and development are complex processes, due to the often complex learning curve, limited training possibilities, and growing restrictions on working hours. Simulation-based training programmes, employing various models, have been proposed. Nevertheless, the extent to which these training programmes are supported by scientific evidence is unclear. The aim of this systematic review is to evaluate the extent and quality of the scientific evidence backing validated microsurgical training programmes. Methods: A systematic literature review was conducted, following a study protocol established a priori and in accordance with the PRISMA guidelines. The databases searched were the Web of Science Core Collection (Web of Knowledge), Medline (Ovid), Embase (Embase.com), and ERIC (Ovid). Studies were included if they described microsurgical training programmes and presented a form of validation of training effectiveness. Data extraction included the number of participants, training duration and frequency, validation type, assessment methods, outcomes, study limitations, and a detailed training regimen. The risk of bias and quality were assessed using the Medical Education Research Study Quality Instrument (MERSQI). Validity was assessed using an established validity framework (content, face, construct, and criterion encompassing both concurrent and predictive validity). The Level of Evidence (LoE) and Recommendation (LoR) were evaluated using the Oxford Centre for Evidence-Based Medicine (OCEBM). Results: A total of 25 studies met the inclusion criteria. Training programmes were classified into one-time intensive courses or longitudinal curricula. Face, content, and construct validity were the most commonly assessed aspects, while predictive validity was the least frequently assessed and not properly evaluated. Training models ranged from low-fidelity (silicone tubes, synthetic vessels) to high-fidelity (live animal models). The Global Rating Scale (GRS), the Structured Assessment of Microsurgery Skills (SAMS), and the Objective Structured Assessment of Technical Skills (OSATS) were the most frequently used objective assessment tools for evaluation methods within the programmes. The risk of bias MERSQI score was 12.96, ranging from 10.5 to 15.5, and LoE and LoR scores were moderated. Across the studies, 96% reported significant improvement in microsurgical skills among participants. However, most studies were limited by small sample sizes, heterogeneity in baseline skills, and a lack of long-term follow-up. Conclusions: While validated microsurgical training programmes improve skill acquisition, challenges remain in terms of standardisation and best cost-effective methods. Future research should prioritise evaluating predictive validity, creating standardised objective assessment tools, and focus on skill maintenance. Full article
(This article belongs to the Special Issue Microsurgery: Current and Future Challenges)
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23 pages, 1612 KB  
Systematic Review
Propeller Flaps for Acute Lower Limb Reconstruction After Trauma: Evidence from a Systematic Review
by Sara Matarazzo, Beatrice Corsini, Silvia Cozzi, Annachiara Tellarini, Luigi Valdatta and Ferruccio Paganini
J. Clin. Med. 2025, 14(17), 6288; https://doi.org/10.3390/jcm14176288 - 5 Sep 2025
Viewed by 865
Abstract
Background: Propeller perforator flaps (PPFs) have gained increasing popularity in lower limb reconstruction. While their use in elective settings is well described, their role in acute post-traumatic reconstruction remains less defined. Methods: A systematic review was conducted following PRISMA 2020 guidelines. PubMed, Scopus, [...] Read more.
Background: Propeller perforator flaps (PPFs) have gained increasing popularity in lower limb reconstruction. While their use in elective settings is well described, their role in acute post-traumatic reconstruction remains less defined. Methods: A systematic review was conducted following PRISMA 2020 guidelines. PubMed, Scopus, and Cochrane Library were searched on 2 June 2025, for studies reporting on the use of propeller flaps in lower limb reconstruction after trauma. Only studies rated as “good” quality using the NIH quality assessment tool were included. Data on anatomical location, flap survival, complications, reinterventions, and functional and patient-reported outcomes were extracted and analyzed descriptively. Results: Twenty-eight studies published between 2008 and 2024 were included, accounting for 619 propeller flaps in a population of 838 patients. The majority of flaps were fasciocutaneous, with the posterior tibial artery being the most commonly used source vessel. Among the flaps included, 422 (68.2%) achieved complete survival without necrosis, 84 (13.6%) developed partial necrosis, and 23 (3.7%) failed completely. Considering all flaps that remained viable after any required revisions or conservative management, the overall survival rate was 97%. Venous congestion was the leading cause of flap compromise. The overall complication rate was 21.8%, increasing to 35.1% in acute trauma cases. A statistically significant correlation was found between wide rotation angles (≥150°) and higher complication rates (p = 0.015). The mean follow-up duration was 12.5 months. Functional and aesthetic outcomes were poorly reported, but when available, they were generally favorable. Conclusions: PPFs represent a valuable option for lower limb reconstruction, providing reliable coverage while preserving major vascular axes. Their application in acute trauma settings appears promising, although current evidence is limited by small verified cohorts and predominantly retrospective study designs. Despite higher complication rates in acute cases, flap survival remains consistently high, supporting their use in carefully selected patients. Further prospective studies with standardized outcome reporting are needed to clarify long-term functional results and refine selection strategies. Full article
(This article belongs to the Special Issue Microsurgery: Current and Future Challenges)
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