Emphasizing evolution of key technological elements in reconstructive surgery_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZAN Tao ,  LI Qingfeng

Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, P. R. China;

Corresponding?author：

LI Qingfeng, Email: dr.liqingfeng@shsmu.edu.cn

Keywords：

Facial reconstruction; reconstructive surgery; regenerative medicine; medical-engineering integration; artificial intelligence

DOI：

10.7507/1002-1892.202512040

Video：

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Reconstructive surgery is fundamentally dedicated to restoring tissues and organs damaged by trauma, disease, or congenital anomalies, with the goal of re-establishing both physiological function and anatomical form. Facial reconstruction, as one of the most representative and technically demanding areas of the discipline, embodies the evolution of its concepts and technological progress. Using facial reconstruction as the point of departure, this article systematically delineates the scientific underpinnings and developmental frontiers of the field. Centered on four core elements—donor construction, vascular reconstruction, precision transplantation, and functional recovery, this article articulates the internal logic and technical considerations of both autologous and allogeneic reconstructive methods. Further, from the perspectives of regenerative donor fabrication, the digital and intelligent transformation of reconstructive surgery, breakthroughs in immune tolerance strategies, and the integration of engineering technologies to enhance functional outcomes, the article envisions potential paradigm shifts that may redefine the discipline. By leveraging facial reconstruction as a highly integrated lens, this work aims to elucidate the key drivers of innovation and chart the future directions of reconstructive surgery.

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2.	Li Q, Zan T, Gu B, et al. Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander. Microsurgery, 2009, 29(7): 515-523.
3.	Huang X, Li Q, Zan T. Total face restoration with autologous tissue: advances and reflections. J Craniofac Surg, 2025, 36(6): 2166-2171.
4.	Zhou SB, Zhang GY, Xie Y, et al. Autologous stem cell transplantation promotes mechanical stretch induced skin regeneration: a randomized phase Ⅰ/Ⅱ clinical trial. EBioMedicine, 2016, 13: 356-364.
5.	Tan PC, Chao PC, Cheng C, et al. A randomized, controlled clinical trial of autologous stromal vascular fraction cells transplantation to promote mechanical stretch-induced skin regeneration. Stem Cell Res Ther, 2021, 12(1): 243. doi: 10.1186/s13287-021-02318-5.
6.	Mathy JA, Pribaz JJ. Prefabrication and prelamination applications in current aesthetic facial reconstruction. Clin Plast Surg, 2009, 36(3): 493-505.
7.	Pribaz JJ, Caterson EJ. Evolution and limitations of conventional autologous reconstruction of the head and neck. J Craniofac Surg, 2013, 24(1): 99-107.
8.	Li H, Gao Y, Gu B, et al. Midface prelamination by using a three-dimensional cervicothoracic prefabricated flap. Plast Reconstr Surg, 2024, 154(1): 182e-185e.
9.	Mohan R, Borsuk DE, Dorafshar AH, et al. Aesthetic and functional facial transplantation: a classification system and treatment algorithm. Plast Reconstr Surg, 2014, 133(2): 386-397.
10.	Sosin M, Rodriguez ED. The face transplantation update: 2016. Plast Reconstr Surg, 2016, 137(6): 1841-1850.
11.	Lantieri L, Meningaud JP, Grimbert P, et al. Repair of the lower and middle parts of the face by composite tissue allotransplantation in a patient with massive plexiform neurofibroma: a 1-year follow-up study. Lancet, 2008, 372(9639): 639-645.
12.	Huang X, Liu D, Gu S, et al. Augmentation of perforator flap blood supply with vascular supercharge or flap prefabrication: evaluation in a rat model. Plast Reconstr Surg, 2021, 147(5): 1105-1115.
13.	Zan T, Li H, Huang X, et al. Augmentation of perforator flap blood supply with sole or combined vascular supercharge and flap prefabrication for difficult head and neck reconstruction. Facial Plast Surg Aesthet Med, 2020, 22(6): 441-448.
14.	Gu S, Khoong Y, Gao Y, et al. Identification of the optimal predictive cutoff value for expanded flap viability using indocyanine green angiography: a prospective study. Burns Trauma, 2024, 12: tkae019. doi: 10.1093/burnst/tkae019.
15.	Huang X, Li H, Gu S, et al. Intraoperative indocyanine green angiography facilitates flap fenestration and facial organ fabrication in total facial restoration. Plast Reconstr Surg, 2024, 153(6): 1416-1424.
16.	Kantar RS, Alfonso AR, Diep GK, et al. Facial transplantation: principles and evolving concepts. Plast Reconstr Surg, 2021, 147(6): 1022e-1038e.
17.	Ceradini DJ, Tran DL, Dedania VS, et al. Combined whole eye and face transplant: microsurgical strategy and 1-year clinical course. JAMA, 2024, 332(18): 1551-1558.
18.	Jiang T, Zhu M, Zan T, et al. A novel augmented reality-based navigation system in perforator flap transplantation-a feasibility study. Ann Plast Surg, 2017, 79(2): 192-196.
19.	Jiang T, Yu D, Wang Y, et al. HoloLens-based vascular localization system: precision evaluation study with a three-dimensional printed model. J Med Internet Res, 2020, 22(4): e16852. doi: 10.2196/16852.
20.	Pan S, Wang L, Ma YZ, et al. Photoacoustic-enabled automatic vascular navigation: accurate and naked-eye real-time visualization of deep-seated vessels. Advanced Photonics Nexus, 2023, 2(4): 31-43.
21.	Tang Y, Guo Q, Li X, et al. Augmented reality-assisted systematic mapping of anterolateral thigh perforators. BMC Musculoskelet Disord, 2022, 23(1): 1047. doi: 10.1186/s12891-022-06013-1.
22.	La Padula S, Pensato R, Pizza C, et al. Face transplant: indications, outcomes, and ethical issues-where do we stand? J Clin Med, 2022, 11(19): 5750. doi: 10.3390/jcm11195750.
23.	Zan T, Wang W, Li H, et al. Autologous tissue repair and total face restoration. JAMA Otolaryngol Head Neck Surg, 2024, 150(8): 695-703.
24.	Khalifian S, Brazio PS, Mohan R, et al. Facial transplantation: the first 9 years. Lancet, 2014, 384(9960): 2153-2163.
25.	Diaz-Siso JR, Sosin M, Plana NM, et al. Face transplantation: Complications, implications, and an update for the oncologic surgeon. J Surg Oncol, 2016, 113(8): 971-975.
26.	Sosin M, Ceradini DJ, Levine JP, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant: a reconstructive solution for the full face and total scalp burn. Plast Reconstr Surg, 2016, 138(1): 205-219.
27.	Goldberg JL. Bringing eye transplant into the light. JAMA, 2024, 332(18): 1523-1524.
28.	Wei J, Baptista-Hon DT, Wang Z, et al. Bioengineered human tissue regeneration and repair using endogenous stem cells. Cell Rep Med, 2023, 4(8): 101156. doi: 10.1016/j.xcrm.2023.101156.
29.	Kim J, Lee SM, Kim DE, et al. Development of an automated free flap monitoring system based on artificial intelligence. JAMA Netw Open, 2024, 7(7): e2424299. doi: 10.1001/jamanetworkopen.2024.24299.
30.	van Mulken TJM, Schols RM, Scharmga AMJ, et al. First-in-human robotic supermicrosurgery using a dedicated microsurgical robot for treating breast cancer-related lymphedema: a randomized pilot trial. Nat Commun, 2020, 11(1): 757. doi: 10.1038/s41467-019-14188-w.
31.	Tolksdorf K, Hohberger FS, Ernst C, et al. First experience using a novel microsurgical robotic device for free flap surgery in cranio- and maxillofacial surgery. J Craniomaxillofac Surg, 2024, 52(6): 704-706.
32.	Homsy P, Huelsboemer L, Barret JP, et al. An update on the survival of the first 50 face transplants worldwide. JAMA Surg, 2024, 159(12): 1339-1345.
33.	Divard G, Aubert O, Debiais-Deschamp C, et al. Long-term outcomes after conversion to a belatacept-based immunosuppression in kidney transplant recipients. Clin J Am Soc Nephrol, 2024, 19(5): 628-637.
34.	Cabezas L, Jouve T, Malvezzi P, et al. Tocilizumab and active antibody-mediated rejection in kidney transplantation: a literature review. Front Immunol, 2022, 13: 839380. doi: 10.3389/fimmu.2022.839380.
35.	Huang K, Zapata D, Tang Y, et al. In vivo delivery of CRISPR-Cas9 genome editing components for therapeutic applications. Biomaterials, 2022, 291: 121876. doi: 10.1016/j.biomaterials.2022.121876.
36.	Georgiev P, Benamar M, Han S, et al. Regulatory T cells in dominant immunologic tolerance. J Allergy Clin Immunol, 2024, 153(1): 28-41.
37.	Reardon S. First pig-to-human heart transplant: what can scientists learn? Nature, 2022, 601(7893): 305-306.
38.	No author list]. First gene-edited pig kidney transplant. Nat Biotechnol, 2024, 42(4): 543. doi: 10.1038/s41587-024-02223-1.
39.	Tao KS, Yang ZX, Zhang X, et al. Gene-modified pig-to-human liver xenotransplantation. Nature, 2025, 641(8064): 1029-1036.
40.	Maeng G, Das S, Greising SM, et al. Humanized skeletal muscle in MYF5/MYOD/MYF6-null pig embryos. Nat Biomed Eng, 2021, 5(8): 805-814.
41.	Mallapaty S. Tiny human hearts grown in pig embryos for the first time. Nature, 2025, 642(8069): 852. doi: 10.1038/d41586-025-01854-x.
42.	Canny E, Vansteensel MJ, van der Salm SMA, et al. Boosting brain-computer interfaces with functional electrical stimulation: potential applications in people with locked-in syndrome. J Neuroeng Rehabil, 2023, 20(1): 157. doi: 10.1186/s12984-023-01272-y.
43.	Holz FG, Le Mer Y, Muqit MMK, et al. Subretinal photovoltaic implant to restore vision in geographic atrophy due to AMD. N Engl J Med, 2025. doi: 10.1056/NEJMoa2501396.

1. Tobin GR, Breidenbach WC, Ildstad ST, et al. The history of human composite tissue allotransplantation. Transplant Proc, 2009, 41(2): 466-471.
2. Li Q, Zan T, Gu B, et al. Face resurfacing using a cervicothoracic skin flap prefabricated by lateral thigh fascial flap and tissue expander. Microsurgery, 2009, 29(7): 515-523.
3. Huang X, Li Q, Zan T. Total face restoration with autologous tissue: advances and reflections. J Craniofac Surg, 2025, 36(6): 2166-2171.
4. Zhou SB, Zhang GY, Xie Y, et al. Autologous stem cell transplantation promotes mechanical stretch induced skin regeneration: a randomized phase Ⅰ/Ⅱ clinical trial. EBioMedicine, 2016, 13: 356-364.
5. Tan PC, Chao PC, Cheng C, et al. A randomized, controlled clinical trial of autologous stromal vascular fraction cells transplantation to promote mechanical stretch-induced skin regeneration. Stem Cell Res Ther, 2021, 12(1): 243. doi: 10.1186/s13287-021-02318-5.
6. Mathy JA, Pribaz JJ. Prefabrication and prelamination applications in current aesthetic facial reconstruction. Clin Plast Surg, 2009, 36(3): 493-505.
7. Pribaz JJ, Caterson EJ. Evolution and limitations of conventional autologous reconstruction of the head and neck. J Craniofac Surg, 2013, 24(1): 99-107.
8. Li H, Gao Y, Gu B, et al. Midface prelamination by using a three-dimensional cervicothoracic prefabricated flap. Plast Reconstr Surg, 2024, 154(1): 182e-185e.
9. Mohan R, Borsuk DE, Dorafshar AH, et al. Aesthetic and functional facial transplantation: a classification system and treatment algorithm. Plast Reconstr Surg, 2014, 133(2): 386-397.
10. Sosin M, Rodriguez ED. The face transplantation update: 2016. Plast Reconstr Surg, 2016, 137(6): 1841-1850.
11. Lantieri L, Meningaud JP, Grimbert P, et al. Repair of the lower and middle parts of the face by composite tissue allotransplantation in a patient with massive plexiform neurofibroma: a 1-year follow-up study. Lancet, 2008, 372(9639): 639-645.
12. Huang X, Liu D, Gu S, et al. Augmentation of perforator flap blood supply with vascular supercharge or flap prefabrication: evaluation in a rat model. Plast Reconstr Surg, 2021, 147(5): 1105-1115.
13. Zan T, Li H, Huang X, et al. Augmentation of perforator flap blood supply with sole or combined vascular supercharge and flap prefabrication for difficult head and neck reconstruction. Facial Plast Surg Aesthet Med, 2020, 22(6): 441-448.
14. Gu S, Khoong Y, Gao Y, et al. Identification of the optimal predictive cutoff value for expanded flap viability using indocyanine green angiography: a prospective study. Burns Trauma, 2024, 12: tkae019. doi: 10.1093/burnst/tkae019.
15. Huang X, Li H, Gu S, et al. Intraoperative indocyanine green angiography facilitates flap fenestration and facial organ fabrication in total facial restoration. Plast Reconstr Surg, 2024, 153(6): 1416-1424.
16. Kantar RS, Alfonso AR, Diep GK, et al. Facial transplantation: principles and evolving concepts. Plast Reconstr Surg, 2021, 147(6): 1022e-1038e.
17. Ceradini DJ, Tran DL, Dedania VS, et al. Combined whole eye and face transplant: microsurgical strategy and 1-year clinical course. JAMA, 2024, 332(18): 1551-1558.
18. Jiang T, Zhu M, Zan T, et al. A novel augmented reality-based navigation system in perforator flap transplantation-a feasibility study. Ann Plast Surg, 2017, 79(2): 192-196.
19. Jiang T, Yu D, Wang Y, et al. HoloLens-based vascular localization system: precision evaluation study with a three-dimensional printed model. J Med Internet Res, 2020, 22(4): e16852. doi: 10.2196/16852.
20. Pan S, Wang L, Ma YZ, et al. Photoacoustic-enabled automatic vascular navigation: accurate and naked-eye real-time visualization of deep-seated vessels. Advanced Photonics Nexus, 2023, 2(4): 31-43.
21. Tang Y, Guo Q, Li X, et al. Augmented reality-assisted systematic mapping of anterolateral thigh perforators. BMC Musculoskelet Disord, 2022, 23(1): 1047. doi: 10.1186/s12891-022-06013-1.
22. La Padula S, Pensato R, Pizza C, et al. Face transplant: indications, outcomes, and ethical issues-where do we stand? J Clin Med, 2022, 11(19): 5750. doi: 10.3390/jcm11195750.
23. Zan T, Wang W, Li H, et al. Autologous tissue repair and total face restoration. JAMA Otolaryngol Head Neck Surg, 2024, 150(8): 695-703.
24. Khalifian S, Brazio PS, Mohan R, et al. Facial transplantation: the first 9 years. Lancet, 2014, 384(9960): 2153-2163.
25. Diaz-Siso JR, Sosin M, Plana NM, et al. Face transplantation: Complications, implications, and an update for the oncologic surgeon. J Surg Oncol, 2016, 113(8): 971-975.
26. Sosin M, Ceradini DJ, Levine JP, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant: a reconstructive solution for the full face and total scalp burn. Plast Reconstr Surg, 2016, 138(1): 205-219.
27. Goldberg JL. Bringing eye transplant into the light. JAMA, 2024, 332(18): 1523-1524.
28. Wei J, Baptista-Hon DT, Wang Z, et al. Bioengineered human tissue regeneration and repair using endogenous stem cells. Cell Rep Med, 2023, 4(8): 101156. doi: 10.1016/j.xcrm.2023.101156.
29. Kim J, Lee SM, Kim DE, et al. Development of an automated free flap monitoring system based on artificial intelligence. JAMA Netw Open, 2024, 7(7): e2424299. doi: 10.1001/jamanetworkopen.2024.24299.
30. van Mulken TJM, Schols RM, Scharmga AMJ, et al. First-in-human robotic supermicrosurgery using a dedicated microsurgical robot for treating breast cancer-related lymphedema: a randomized pilot trial. Nat Commun, 2020, 11(1): 757. doi: 10.1038/s41467-019-14188-w.
31. Tolksdorf K, Hohberger FS, Ernst C, et al. First experience using a novel microsurgical robotic device for free flap surgery in cranio- and maxillofacial surgery. J Craniomaxillofac Surg, 2024, 52(6): 704-706.
32. Homsy P, Huelsboemer L, Barret JP, et al. An update on the survival of the first 50 face transplants worldwide. JAMA Surg, 2024, 159(12): 1339-1345.
33. Divard G, Aubert O, Debiais-Deschamp C, et al. Long-term outcomes after conversion to a belatacept-based immunosuppression in kidney transplant recipients. Clin J Am Soc Nephrol, 2024, 19(5): 628-637.
34. Cabezas L, Jouve T, Malvezzi P, et al. Tocilizumab and active antibody-mediated rejection in kidney transplantation: a literature review. Front Immunol, 2022, 13: 839380. doi: 10.3389/fimmu.2022.839380.
35. Huang K, Zapata D, Tang Y, et al. In vivo delivery of CRISPR-Cas9 genome editing components for therapeutic applications. Biomaterials, 2022, 291: 121876. doi: 10.1016/j.biomaterials.2022.121876.
36. Georgiev P, Benamar M, Han S, et al. Regulatory T cells in dominant immunologic tolerance. J Allergy Clin Immunol, 2024, 153(1): 28-41.
37. Reardon S. First pig-to-human heart transplant: what can scientists learn? Nature, 2022, 601(7893): 305-306.
38. No author list]. First gene-edited pig kidney transplant. Nat Biotechnol, 2024, 42(4): 543. doi: 10.1038/s41587-024-02223-1.
39. Tao KS, Yang ZX, Zhang X, et al. Gene-modified pig-to-human liver xenotransplantation. Nature, 2025, 641(8064): 1029-1036.
40. Maeng G, Das S, Greising SM, et al. Humanized skeletal muscle in MYF5/MYOD/MYF6-null pig embryos. Nat Biomed Eng, 2021, 5(8): 805-814.
41. Mallapaty S. Tiny human hearts grown in pig embryos for the first time. Nature, 2025, 642(8069): 852. doi: 10.1038/d41586-025-01854-x.
42. Canny E, Vansteensel MJ, van der Salm SMA, et al. Boosting brain-computer interfaces with functional electrical stimulation: potential applications in people with locked-in syndrome. J Neuroeng Rehabil, 2023, 20(1): 157. doi: 10.1186/s12984-023-01272-y.
43. Holz FG, Le Mer Y, Muqit MMK, et al. Subretinal photovoltaic implant to restore vision in geographic atrophy due to AMD. N Engl J Med, 2025. doi: 10.1056/NEJMoa2501396.

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