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Page 2 of 10 Hammond et al. Plast Aesthet Res 2024;11:28 https://dx.doi.org/10.20517/2347-9264.2024.27

Subsequent adoption of this technology within other surgical specialties such as general surgery, thoracic
surgery, gynecologic surgery, and otolaryngologic surgery illustrates that robotic surgery enhances operative
ergonomics by providing three-dimensional optics at 10× magnification, increasing precision with 5:1
[2]
motion scaling, and eliminating tremor . A robotic approach to breast reconstruction was first described in
2006 by Boyd et al for the harvest of intermammary recipient vessels among 20 patients undergoing
[3]
autologous tissue transfer .
Arising from the premise of a robotic approach to recipient vessel dissection, literature describing a full
robotic approach to workhorse flaps first appeared in 2011 with the harvest of 10 robotic latissimus dorsi
muscle flaps in a cadaveric model . These techniques were subsequently applied clinically to harvest
[4]
[5]
pedicled latissimus muscle flaps for breast reconstruction . Robotic latissimus muscle flap harvest affords
distinct advantages to a traditional open approach, notably an 80-88% reduction of the donor site incision
and better circumnavigation of the back with high-resolution optics and superior ergonomics. To further
maximize the precision of autologous breast reconstruction while minimizing donor-site morbidity, a
robotic approach to the deep inferior epigastric perforator (DIEP) flap was also developed . Traditional
[6,7]
DIEP flap harvest requires significant disruption of the abdominal wall to effectively isolate necessary
perforators and obtain the pedicle length necessary for microsurgery. While dissection utilizing lateral row
perforators results in less intramuscular dissection, this approach puts motor nerves at higher risk of
[8]
violation, leading to abdominal wall weakness, bulging, or hernia . Robotic DIEP flap harvest utilizes a
submuscular approach for pedicle dissection, sparing motor nerves with a much smaller fascial incision,
minimizing the risk for donor-site morbidity.

In this chapter, we will fully characterize the preoperative planning, operative anatomy & techniques, and
clinical outcomes regarding the robotic harvest of two workhorse flaps in autologous breast reconstruction,
the latissimus muscle flap and DIEP flap. All aspects of this chapter were conducted and are presented in
ethical accordance with the Declaration of Helsinki, with the approved secondary use of de-identified
figures and photographs obtained through patient written-informed consent; these methods meet
Institutional Review Board rules and standards of approval for exemption.

CLINICAL CONSIDERATIONS
While full clinical adoption of robotic latissimus and DIEP flap harvest is steadily gaining traction in
current literature, it is still only practiced in notable volumes at a small number of centers. The absence of
an FDA-approved clinical indication in plastic surgery renders any use of the robot in breast reconstruction
off-label. Only recently has a prospective study been performed under an investigational device exemption
through the FDA for obtaining 510(k) approval, demonstrating the safety of the da Vinci Surgical System
(Intuitive Surgical, Sunnyvale, CA) for robotic latissimus dorsi harvest; this remains to be performed for
robotic DIEP flap harvest . Despite being off-label, robotic breast reconstruction allows for minimal
[9]
incisions and decreased donor site morbidity when performed in select patients.

Robotic latissimus muscle flap harvest is clinically indicated for patients with thin mastectomy flaps and
increased risk of implant exposure, or capsular contracture requiring capsulectomy after adjuvant radiation
therapy who may otherwise not be candidates for free tissue transfer. These are reconstructive scenarios
[10]
whereby latissimus muscle flap coverage may be beneficial to protect an implant . Robotic DIEP flap
harvest is ideal in scenarios whereby the surgeon seeks to minimize violation of the anterior rectus sheath,
abdominal wall nerves, and rectus musculature.