Freehand Procedures Research Articles

In vitro comparison of guide planes for removable partial dentures prepared with CAD-CAM-assisted templates, guiding rod templates, and freehand

ObjectivesThis study aimed to evaluate the accuracy of computer-aided design and computer-aided manufacturing (CAD-CAM)-assisted templates (CCAT), guiding rod templates (GRT), and freehand (FH) preparation of guide planes. MethodsForty-five identical maxillary resin casts were divided into three groups, in which the guide planes of the two abutment teeth were prepared using a CCAT (n=15), GRT (n=15), and FH (n=15). The CCAT and GRT were digitally designed on a digital cast of virtually prepared guide planes and fabricated using three-dimensional printing (3DP) technology. To assess the 3D trueness, the prepared guide planes were digitally scanned and compared to the virtually designed guide planes. The angle deviation was measured to assess the trueness of the direction of the guide plane preparation. Shapiro–Wilk and Levene's tests were used to check the normality and equivalence of the variance of the data. The data were compared by using the Kruskal‒Wallis H test (α=0.05). ResultsThe CCAT group exhibited significantly better 3D trueness (78.5±19.8 μm) than the GRT group (211.3±42.4 μm, p<0.05) and the FH group (198.9±44.3 μm, p<0.05). Additionally, the CCAT group (1.31±0.50°) showed significantly smaller direction trueness compared to the GRT (4.65±0.72°, p<0.05) and FH (5.64±0.70°, p<0.05) groups. ConclusionsThe novel CAD-CAM-assisted template significantly improved the quality of the guide planes compared with the GRT and FH procedures. This enhancement suggests that removable partial dentures can be predictably inserted immediately after guide plane preparation. Clinical SignificanceCAD-CAM-assisted templates improve the quality of guide plane preparation.

Accuracy of open-sleeved vs. closed-sleeved static computer-assisted implant systems in immediate maxillary molar implant placement: An invitro study.

The objective of this study is (1) to compare the accuracy of an open-sleeved static computer-assisted implant system (sCAIS) with a closed-sleeve sCAIS and free-hand approach in immediate implant placement (IIP) of maxillary molar sites and (2) to investigate the influence of socket morphology on these approaches. Ninety partially edentulous duplicated maxillary models simulating three different molar sockets (type A, B, and C based on Smith and Tarnow's classification) were investigated. Three modalities, including sCAIS with open-sleeves, sCAIS with closed-sleeves, and free-hand approach, were applied separately to 30 models with 120 sockets. A customized Python script automatically measured the deviations between the virtual and actual implant positions for all 360 implants. The 3D deviations of sCAIS were significantly influenced by the socket and sleeve types. Both guided groups exhibited significantly less deviation than the free-hand approach. Type A and C sockets resulted in better implant positions than type B socket sites. In type B sockets, the open-sleeve group achieved significantly less deviation compared to the closed-sleeve group, with respect to apical global (1.34 ± 0.53 vs. 1.84 ± 0.59 mm), coronal horizontal (0.68 ± 0.36 vs. 0.93 ± 0.34 mm), apical horizontal (1.21 ± 0.59 vs. 1.74 ± 0.63 mm), and angular (3.30 ± 1.41 vs. 4.41 ± 1.96°) deviations. Guided implant surgery significantly reduces deviations during molar IIP compared to free-hand procedures. Furthermore, the use of open-sleeve sCAIS appears to be more effective in minimizing deviations in type B sockets when compared with the closed-sleeve guided system.

Accuracy Comparison between Robot-Assisted Dental Implant Placement and Static/Dynamic Computer-Assisted Implant Surgery: A Systematic Review and Meta-Analysis of In Vitro Studies.

Background and Objectives: The present systematic review and meta-analysis undertake a comparison of studies that examine the accuracy of robot-assisted dental implant placement in relation to static computer-assisted implant surgery (SCAIS), dynamic computer-assisted implant surgery (DCAIS), and freehand procedures. This study aims to provide a comprehensive understanding of the precision of robot-assisted dental implant placement and its comparative efficacy in relation to other placement techniques. Methods: The guidelines recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used to organize and compose this review. Four electronic databases (PubMed, Web of Science, Scopus, and Cochrane) were systematically searched for pertinent articles. Articles were selected following the inclusion and exclusion criteria. Qualitative and quantitative analyses of the selected articles were performed. Results: The initial electronic search resulted in 1087 hits. Based on the inclusion and exclusion criteria, five articles were selected for qualitative analysis, out of which three were considered for quantitative analysis. Three parameters were considered for accuracy evaluation (angular, coronal, and apical deviation). The mean angular deviation was -1.22 degrees (95% CI, -1.06--1.39), the mean coronal deviation was -0.15 mm (95% CI, -0.24--0.07), and the mean apical deviation was -0.19 mm (95% CI, -0.27--0.10). Conclusions: The robotic implant system was found to have significantly lower angular deviations and insignificantly lower coronal and apical deviations compared to DCAIS. Within the limitations of this review, it can be concluded that robot-assisted implant placement in resin models permits higher accuracy compared to DCAIS and SCAIS systems. However, due to the limited number of comparative studies with high heterogeneity, the findings of this review should be interpreted with caution. Further research is necessary to confirm the clinical application of robotics in implant surgery.

Robotic versus freehand CT-guided radiofrequency ablation of pulmonary metastases: a comparative cohort study

PurposeRadiofrequency ablation (RFA) is a curative treatment option for small lung metastases, which conventionally involves multiple freehand manipulations until the treating electrode is satisfactorily positioned. Stereotactic and robotic guidance has been gaining popularity for liver ablation, although has not been established in lung ablation. The purpose of this study is to determine the feasibility, safety, and accuracy of robotic RFA for pulmonary metastases, and compare procedures with a conventional freehand cohort.MethodsA single center study with prospective robotic cohort, and retrospective freehand cohort. RFA was performed under general anesthesia using high frequency jet ventilation and CT guidance. Main outcomes were (i) feasibility/technical success (ii) safety using Common Terminology Criteria for Adverse Events (iii) targeting accuracy (iv) number of needle manipulations for satisfactory ablation. Robotic and freehand cohorts were compared using Mann–Whitney U tests for continuous variables, and Fisher’s exact for categorical variables.ResultsThirty-nine patients (mean age 65 ± 13 years, 20 men) underwent ablation of 44 pulmonary metastases at single specialist cancer center between July 2019 and August 2022. 20 consecutive participants underwent robotic ablation, and 20 consecutive patients underwent freehand ablation. All 20/20 (100%) robotic procedures were technically successful, and none were converted to freehand procedures. There were 6/20 (30%) adverse events in the robotic cohort, and 15/20 (75%) in the freehand cohort (P = 0.01). Robotic placement was highly accurate with 6 mm tip-to-target distance (range 0–14 mm) despite out-of-plane approaches, with fewer manipulations than freehand placement (median 0 vs. 4.5 manipulations, P < 0.001 and 7/22, 32% vs. 22/22, 100%, P < 0.001).ConclusionsRobotic radiofrequency ablation of pulmonary metastases with general anesthesia and high frequency jet ventilation is feasible and safe. Targeting accuracy is high, and fewer needle/electrode manipulations are required to achieve a satisfactory position for ablation than freehand placement, with early indications of reduced complications.

Evaluation of the performance of robot assisted CT-guided percutaneous needle insertion: Comparison with freehand insertion in a phantom

PurposeTo evaluate the performance of a novel robot for CT-guided needle positioning procedures and compare it to the freehand technique in an abdominal phantom. MethodsOne interventional radiology fellow and one experienced interventional radiologist (IR) performed twelve robot-assisted and twelve freehand needle positionings in a phantom over predetermined trajectories. The robot automatically aimed a needle-guide according to the planned trajectories, after which the clinician manually inserted the needle. Using repeated CT scans, the needle position was assessed and adjusted if the clinician deemed it necessary. Technical success, accuracy, number of position adjustments, and procedure time were measured. All outcomes were analyzed using descriptive statistics and were compared between the robot-assisted and freehand procedures using the paired t-test and Wilcoxon signed rank test. ResultsCompared with the freehand technique, the robot system improved the number of technically successfully needle targeting (20/24 vs 14/24), with higher accuracy (mean Euclidean deviation from target center: 3.5 ± 1.8 mm vs 4.6 ± 2.1 mm, p = 0.02) and required fewer needle position adjustments (0.0 ± 0.2 steps vs 1.7 ± 0.9 steps, p < 0.001), respectively. The robot improved the needle positioning for both, the fellow and the expert IR, compared to their freehand performances, with more improvement for the fellow than for the expert IR. The procedure time was similar for the robot-assisted and freehand procedures (19.5 ± 9.2 min. vs 21.0 ± 6.9 min., p = 0.777). ConclusionsCT-guided needle positioning with the robot was more successful and accurate than freehand needle positioning and required fewer needle position adjustments without prolonging the procedure.

Robotic laser position versus freehand in CT-guided percutaneous microwave ablation for single hepatocellular carcinoma (diameter < 3 cm): a preliminary study

Purpose To compare the accuracy and safety of robotic laser position (RLP) versus freehand for antenna CT-guided microwave ablation (MWA) of single hepatocellular carcinoma (HCC) (diameter < 3 cm). Materials and methods This retrospective study was conducted between May 2020 and June 2021. A total of 40 patients with early HCC who underwent CT-guided MWA were divided into two groups: a freehand group (n = 20) and a RLP group (n = 20). Based on in-plane and out-of-plane data, the actual puncture point error (APPE), number of repositioning procedures, and operative duration were compared using the Mann–Whitney U test. Ablation-related complications were compared using the Chi-squared test. Results The mean diameter of HCC patients who received MWA was 2.4 ± 0.5 cm. For in-plane APPE, APPE was comparable between the two groups (p = 0.299). However, for the out-of-plane position, the APPE in the freehand group was higher than that in the RLP group (p = 0.027). The number of repositioning procedures was 0 (range, 0–0) for RLP-guided procedures and 3 (range, 2–5) for freehand procedures, showing a statistically significant difference between the two groups (p < 0.001). The mean operative duration for freehand procedures was 39 min, compared with 26 min for RLP-guided procedures, showing a significant difference (p = 0.013). No deaths or major complications were directly related to MWA. Minor complications in the freehand group were comparable with those in the RLP group (p = 0.313). Conclusion RLP guidance significantly reduces the number of antenna repositioning procedures in MWA and improves puncture accuracy for target HCC out-of-plane. In addition, the operative duration of robotic guidance was shorter than that of freehand guidance.

Efficacy of Shadow-Based Needle Positioning System in Performing CT Image-Guided Percutaneous Biopsy of Lung Lesions: Our Initial Experience.

Context Computerized tomography (CT) is widely used for various interventions and there is a need for an effective navigation tool, for best outcomes. Aim The study was performed to evaluate the efficacy of light- and shadow-based needle positioning assistance device, an innovative navigation tool over the conventional freehand technique, in performing CT image-guided percutaneous interventions. Settings and Design This randomized control trial was performed among patients undergoing CT-guided percutaneous intervention for lung pathologies. Methodology A total of 60 participants were randomized into an intervention group and a control group. The accuracy of needle insertion and other efficacy parameters were assessed for both groups. Post needle placement, CT images were used to evaluate the study endpoints. Statistical Analysis Statistical analysis was performed using SPSS ver. 20 software. Results The mean needle positioning accuracy was 2.1 mm in the experimental group compared with 7.2 mm in the control group freehand procedures. The average time to position the needle at the desired target location was 2.5 minutes in the assisted procedure as compared with 5.3 minutes in the freehand procedure ( p < 0.05). The total number of check scans required to position the needle was 1.3 for assisted procedures and 1.9 for freehand procedures. Conclusion The use of shadow-based assistance device for CT-guided interventions is proven to be efficient and safer with high needle positioning accuracy.

Revisions for screw malposition and clinical outcomes after robot-guided lumbar fusion for spondylolisthesis.

OBJECTIVE The accuracy of robot-guided pedicle screw placement has been proven to be high, but little is known about the impact of such guidance on clinical outcomes such as the rate of revision surgeries for screw malposition. In addition, there are very few data about the impact of robot-guided fusion on patient-reported outcomes (PROs). Thus, the clinical benefit for the patient is unclear. In this study, the authors analyzed revision rates for screw malposition and changes in PROs following minimally invasive robot-guided pedicle screw fixation. METHODS A retrospective cohort study of patients who had undergone minimally invasive posterior lumbar interbody fusion (MI-PLIF) or minimally invasive transforaminal lumbar interbody fusion was performed. Patients were followed up clinically at 6 weeks, 12 months, and 24 months after treatment and by mailed questionnaire in March 2016 as a final follow-up. Visual analog scale (VAS) scores for back and leg pain severity, Oswestry Disability Index (ODI), screw revisions, and socio-demographic factors were analyzed. A literature review was performed, comparing the incidence of intraoperative screw revisions and revision surgery for screw malposition in robot-guided, navigated, and freehand fusion procedures. RESULTS Seventy-two patients fit the study inclusion criteria and had a mean follow up of 32 ± 17 months. No screws had to be revised intraoperatively, and no revision surgery for screw malposition was needed. In the literature review, the authors found a higher rate of intraoperative screw revisions in the navigated pool than in the robot-guided pool (p < 0.001, OR 9.7). Additionally, a higher incidence of revision surgery for screw malposition was observed for freehand procedures than for the robot-guided procedures (p < 0.001, OR 8.1). The VAS score for back pain improved significantly from 66.9 ± 25.0 preoperatively to 30.1 ± 26.8 at the final follow-up, as did the VAS score for leg pain (from 70.6 ± 22.8 to 24.3 ± 28.3) and ODI (from 43.4 ± 18.3 to 16.2 ± 16.7; all p < 0.001). Undergoing PLIF, a high body mass index, smoking status, and a preoperative ability to work were identified as predictors of a reduction in back pain. Length of hospital stay was 2.4 ± 1.1 days and operating time was 161 ± 50 minutes. Ability to work increased from 38.9% to 78.2% of patients (p < 0.001) at the final follow-up, and 89.1% of patients indicated they would choose to undergo the same treatment again. CONCLUSIONS In adults with low-grade spondylolisthesis, the data demonstrated a benefit in using robotic guidance to reduce the rate of revision surgery for screw malposition as compared with other techniques of pedicle screw insertion described in peer-reviewed publications. Larger comparative studies are required to assess differences in PROs following a minimally invasive approach in spinal fusion surgeries compared with other techniques.

Potential accuracy of navigated K-wire guided supra-acetabular osteotomies in orthopedic surgery: a CT fluoroscopy cadaver study.

The aim of this study was to evaluate the accuracy of supra-acetabular pelvic tumor resections in human, full-body cadavers and under realistic operation room conditions with the help of a navigation system and K-wires as guidance for the oscillating saw. Seven hemipelvises from fresh, human, male, full-body cadavers were used. A preoperative and a postoperative CT was performed. Under control of the navigation system K-wires were inserted and served as guidance for the oscillating saw to reduce the error by vibration and jerking movements. The accuracy of the computer aided resections was compared with the accuracy of freehand resections in customized 3D printed pelvises with geometries identical to the cadavers used. The mean deviation of the navigated osteotomies was 1.9 mm (standard deviation 1.0 mm) significantly (P < 0.001) lower than the mean deviation of freehand osteotomies at 9.2 mm (standard deviation 3.7 mm). Navigated K-wires for supra-acetabular osteotomies allow significantly higher accuracy than freehand procedures under simulated operation room conditions. Copyright © 2016 John Wiley & Sons, Ltd.

Posterior C1-C2 transarticular screw fixation for atlantoaxial instability assisted by intraoperative 3-dimensional fluoroscopy-based navigation

To assess the feasibility, efficacy and indication of posterior C1-C2 transarticular screw fixation for atlantoaxial instability assisted by intraoperative 3-dimensional fluoroscopy-based navigation. From November 2005 to October 2012, 58 patients with atlantoaxial instability underwent posterior C1-C2 transarticular screw fixation assisted by intraoperative 3-dimensional fluoroscopy-based navigation. Those with excellent atlantoaxial reduction and no need for decompression underwent percutaneously minimally invasive procedures. Operative duration, blood loss volume, reduction of atlantoaxial joints and postoperative neurovascular complications were recorded. Screw positions were studied by postoperative computed tomography (CT) and divided into 3 categories. The follow-up period was at least 3 months. Local symptoms (assessed by visual analogue scale (VAS) score), neurological conditions (Nurick classification) and bone graft fusion were evaluated. Among them, the procedure was either open surgery (n = 51) or percutaneously minimally invasive surgery (n = 7). A total of 111 screws were placed satisfactorily. Five patients underwent only unilateral C1-C2 transarticular screw fixation. No severe complications were encountered. The mean operative duration was 202.2 ± 54.2 minutes and the average volume of blood loss 412.6 ± 281.2 ml. And the values were comparable to those for the traditional fluoroscopy-guided free-hand procedures. No statistical significance existed between open and percutaneously minimally invasive procedures in operative duration, blood loss volume and precision of screw placement. The patients with incompletely reduced C1-C2 dislocation had comparable clinical outcomes with those with complete reduction. After a 3-month follow-up, all of them showed significant improvements of local symptoms. VAS score decreased from 4.5 ± 1.3 preoperatively to 0.7 ± 0.8 postoperatively while the Nurick classification improved from 2.4 ± 1.1 to 0.6 ± 1.0. And bone graft fusion was satisfactory. Posterior C1-C2 transarticular screw fixation for atlantoaxial instability assisted by intraoperative 3-dimensional fluoroscopy-based navigation is both feasible and safe. Combined with minimally invasive techniques, this procedure may achieve greater precision and minimal invasion.

Prospective Comparison of Freehand and Electromagnetic Needle Tracking for US-guided Percutaneous Liver Biopsy

PurposeTo prospectively compare electromagnetic needle tracking (EMT) and freehand ultrasound (US)-guided liver biopsies. Materials and MethodsAmong 60 consecutive US-guided liver biopsies performed by staff radiologists (senior operators) and residents (junior operators), 30 were performed freehand and 30 with EMT. Needle placement time, numbers of needle punctures and pullbacks, and subjective scores of procedure difficulty were compared by χ2 or Student t test. ResultsDiagnostic success rates, defined by the procurement of an adequate histopathologic specimen, were 96.6% for freehand biopsy and 100% with EMT. Needle placement time was significantly lower for EMT (mean ± standard deviation, 45.8 s ± 48.1) than for freehand procedures (143.2 s ± 122.1; P < .01). In the freehand group, needle placement times were 179.6 seconds ± 133.3 for junior operators and 106.8 seconds ± 101.3 for senior operators (P = .15). In the EMT group, needle placement times were 49.2 seconds ± 55 for junior operators and 42.5 seconds ± 41.2 for senior operators (P = .53). The number of needle pullbacks was significantly lower for senior operators (1.2 ± 0.80) compared with junior operators (2.4 ± 1.4) in the freehand group (P = .01), with no significant difference (junior, 0.47 ± 0.92; senior, 0.67 ± 0.72; P = .24) in the EMT group. The postprocedural difficulty score was lower in the EMT group (1.5 ± 0.7) than in the freehand group (2.1 ± 1.1; P = .02). Needle placement time and number of needle pullbacks were lower in the EMT group, even after taking into account tumor size and depth and operator experience. ConclusionsThe EMT procedure shortens needle placement time and reduces the number of needle pullbacks needed for redirection, regardless of operator experience.

Assessment of Needle Guidance Devices for Their Potential to Reduce Fluoroscopy Time and Operator Hand Dose during C-Arm Cone-Beam Computed Tomography–guided Needle Interventions

PurposeTo assess whether the use of needle guidance devices can reduce fluoroscopy time and operator hand dose during cone-beam computed tomography–guided needle interventions. Materials and MethodsThe freehand technique was compared with techniques employing two distinct needle holders and a ceiling-mounted laser guidance technique. Laser guidance was used either alone or in combination with needle holders. Four interventional radiologists were instructed to reach predetermined targets in an abdominal phantom using these techniques. Each operator used all six techniques three times. Fluoroscopy time, procedure time, operator hand dose, and needle tip deviation were obtained for all simulated needle interventions. All data are presented as median (ranges). ResultsAll procedures were successfully completed within 2–4 minutes, resulting in a deviation from target of 0.8 mm (0–4.7). In freehand procedures, the fluoroscopy time to reach the target was 50 seconds (31–98 s). Laser guidance, used alone or in combination with needle holders, reduced fluoroscopy time to 31 seconds (14–68 s) (P<.02). The operator hand dose in freehand procedures was 275 μSv (20–603 μSv). Laser guidance alone or in combination with needle holders resulted in a reduction of the hand dose to<36 μSv (5–82 μSv) per procedure (P<.001). There were no statistically significant effects on hand dose levels or fluoroscopy time when the needle holders were employed alone. ConclusionsCompared with the freehand technique, all three tested needle guidance devices performed with equivalent efficiency in terms of accuracy and procedure time. Only the addition of laser guidance was found to reduce both fluoroscopy time and operator hand dose.

Active tremor cancellation by a “Smart” handheld vitreoretinal microsurgical tool using swept source optical coherence tomography

Microsurgeons require dexterity to make precise and stable maneuvers to achieve surgical objectives and to minimize surgical risks during freehand procedures. This work presents a novel, common path, swept source optical coherence tomography-based "smart" micromanipulation aided robotic-surgical tool (SMART) that actively suppresses surgeon hand tremor. The tool allows enhanced tool tip stabilization, more accurate targeting and the potential to lower surgical risk. Freehand performance is compared to smart tool-assisted performance and includes assessment of the one-dimensional motion tremor in an active microsurgeon's hand. Surgeon hand tremor-the ability to accurately locate a surgical target and maintain tool tip offset distances-were all improved by smart tool assistance.

Computer-Assisted and Robot-Assisted Technologies to Improve Bone-Cutting Accuracy When Integrated with a Freehand Process Using an Oscillating Saw

In orthopaedic surgery, many interventions involve freehand bone cutting with an oscillating saw. Such freehand procedures can produce large cutting errors due to the complex hand-controlled positioning of the surgical tool. This study was performed to investigate the potential improvements in cutting accuracy when computer-assisted and robot-assisted technologies are applied to a freehand bone-cutting process when no jigs are available. We designed an experiment based on a geometrical model of the cutting process with use of a simulated bone of rectangular geometry. The target planes were defined by three variables: a cut height (t) and two orientation angles (beta and gamma). A series of 156 cuts were performed by six operators employing three technologically different procedures: freehand, navigated freehand, and robot-assisted cutting. After cutting, we measured the error in the height t, the absolute error in the angles beta and gamma, the flatness, and the location of the cut plane with respect to the target plane. The location of the cut plane averaged 2.8 mm after use of the navigated freehand process compared with 5.2 mm after use of the freehand process (p < 0.0001). Further improvements were obtained with use of the robot-assisted process, which provided an average location of 1.7 mm (p < 0.0001). Significant improvements in cutting accuracy can be achieved when a navigation system or an industrial robot is integrated into a freehand bone-cutting process when no jigs are available. The procedure for navigated hand-controlled positioning of the oscillating saw appears to be easy to learn and use.

Application Accuracy of an Electromagnetic Field-Based Image-Guided Navigation System

Objective: We tested the application accuracy of an electromagnetic field-based image guidance system to compare it to traditional optically tracked systems. Methods: A plastic skull phantom was fitted with fiducial markers rigidly attached via self-drilling bone screws. Volumetric CT scan was obtained to simulate the clinical condition. A metal disc marked in 1-mm increments was placed at the expected target point. Following registration and alignment of a trajectory guide, radial and depth localization errors were measured after both freehand and stabilized approaches on both the right and left sides. Statistical analyses of the localization errors were performed. Results: Total target localization error ranged from 0.71 to 3.51 mm with a mean ± SEM of 2.13 ± 0.11 mm. The radial error averaged 0.98 ± 0.11 mm, depth error 1.74 ± 0.13 mm. The freehand procedures produced a statistically greater radial, depth and total error than the fixed procedures. Conclusions: Accuracy of image-guided localization using an electromagnetic field guidance system is similar to that reported for optically guided systems.

Frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles: a simple modification to free-hand procedures

The aim of this report is to introduce a simple modification to the free-hand frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles. In this technical note, we describe our experience with ventricular catheter placement in two children suffering from shunt dependent idiopathic intracranial hypertension using an image-guided instrument holder with a catheter guide. In both patients, the surgical procedure proved to be easy and accurate, with good initial clinical results. The use of an image-guided instrument holder is a modification to the free-hand frameless stereotactic placement of ventriculoperitoneal shunts in undersized ventricles.

Freehand Technique to Harvest Partial-Thickness Skin to Repair Superficial Facial Defects

The freehand-scalpel technique to harvest skin for grafting is a forgotten surgical art. Modern facial surgeons prefer to use local skin flaps or Wolfe-type full grafts to repair facial defects. To determine the relative merits and cosmetic results of freehand skin grafts to cover facial defects following Mohs surgery. We used the freehand-scalpel technique to harvest skin from the periauricular region of the neck and cheek, and other sites. After a local anesthetic is injected the number 15 or 10 blade is used to harvest skin by sequential tangential incisions. The average dermal thickness was about 1.0 mm. To improve cosmetic appearance, the overall shape and thickness of the graft was contoured during harvesting to fit cosmetic unit or facial line. For more than 5 years we have used the freehand technique to repair superficial facial defects of the nose, ear, scalp, temple, forehead, and other nonhead sites. A total of 65 freehand procedures were performed to repair facial defects. The distribution of the anatomic sites and sizes are presented. The size ranged from less than 1 cm to greater than 5 cm in diameter. Three typical cases are presented to illustrate the gratifying results that can be obtained with this technique. In selected sites and patients, the freehand graft is a rapid and convenient method of harvesting skin. When harvested from the preauricular cheek and subauricular neck, the graft is a good match to cover sun-exposed defects of the nose and ear. The major advantages of the freehand technique are that: 1) it expands the number of potential donor sites from which to select the most compatible skin to cover facial defects; 2) it allows the surgeon to efficiently configure the graft to the desired shape and depth to conform to the cosmetic unit or defect that is being reconstructed; 3) it does not require a dermatome or other specialized instrument to perform; and 4) it achieves wound repair with good appearance and function. The freehand partial-thickness skin graft has become our preferred method of grafting superficial facial defects.