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Page 6 of 16 Allam et al. Plast Aesthet Res 2024;11:19 https://dx.doi.org/10.20517/2347-9264.2024.21

associated complications [18,19] . This approach could enable the learning and selection of perforators that
[13]
optimize clinical outcomes .
INTRAOPERATIVE INNOVATIONS
Background
There are various intraoperative targets for optimizing outcomes in breast microsurgical reconstruction,
including advancing surgical techniques and improving methods for evaluating successful flap perfusion.

DIEP flap reconstruction has been associated with significant donor site morbidity, with potential
complications such as abdominal wall herniation, chronic pain, and weakness. This is in part due to the
large incision through the rectus fascia to dissect the vascular pedicle, which can potentially be minimized
[20]
using minimally-invasive techniques . Previous attempts employed technologies like the Da Vinci robotic
system, but fell short due to lack of suitability for meticulous microsurgical procedures. As the realm of
biotechnology expands, robotic platforms specific to microsurgery will enable optimization of techniques,
providing new opportunities to improve breast reconstruction procedures [21,22] .

Autologous breast reconstruction also carries the risk of fat necrosis and flap failure, which, despite recent
advances, still remains high in up to 14% of patients . To prevent these complications, flap viability must
[23]
be accurately identified in the operating room. Currently, this is mainly accomplished using clinical
judgment and subjective evaluation of the flap, such as color, temperature, capillary refill, and bleeding.
While significant clinical experience confers some accuracy, clinical judgment alone falls short at times in
[24]
identifying inadequate flap perfusion . Recent technologies to be implemented for flap perfusion
assessment include indocyanine green (ICG) fluorescence angiography and hyperspectral imaging
(HSI) [21,25,26] .

Robotic-assisted microsurgery
Robotic-assisted surgery, initially popularized in visceral and urological surgeries, has now made significant
inroads into plastic surgery, including autologous breast reconstruction [27-29] . Early adaptation of robotic
systems focused on their utility in harvesting free flaps. Roy et al. conducted a systematic review identifying
two primary robotic-assisted breast reconstruction procedures using the Da Vinci Robotic system
(Sunnyvale, California): a total of 240 DIEP and latissimus dorsi (LD) flap dissections were completed
between 2006-2022. They observed that the total operative time for both DIEP and LD robotic-assisted
procedures was, on average, 49 min longer than the reference data. However, the re-operation rate in
robotic-assisted surgeries was significantly lower. Additionally, preliminary data indicated reduced pain at
the recipient site and higher patient satisfaction scores (BREAST-Q tool) following robotic-assisted
[30]
harvest . Paralleling these findings, Khan et al. reviewed 56 robotic-assisted DIEP flap harvest procedures
and noted decreased postoperative pain, shorter hospital stays, and improved patient-reported outcomes,
[20]
albeit with increased operative times and costs . Multiple separate case series have reported successful
outcomes using the da Vinci Xi robot for robotic-assisted DIEP flaps with no flap failures or abdominal wall
donor site morbidity postoperatively [31,32] . Robotic harvesting techniques are safe, reproducible, and feasible
in a daily hospital setting and offer benefits such as improved visualization, increased dexterity, greater
precision, and reduced surgeon fatigue due to better ergonomics . However, conventional robotic systems
[32]
like the Da Vinci system were not specifically designed for microsurgery, particularly microvascular
anastomoses, as they are too large and robust, with suboptimal optics and magnification, and inability to
scale movements precisely [33,34] .