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Page 12 of 16 Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11

surprisingly poorer for robotic surgery compared to transvaginal and v-NOTES, which may be related to
abdominal scars and gas insufflation. Complications were relatively similar across all studies.

In our center, we perform robotic-assisted TLH ± BSO, with concomitant robotic-assisted transabdominal
vaginectomy if desired by the patient, as a day-case procedure. A combined approach to robotic TLH ± BSO
and vaginectomy may improve surgical efficiency, promote shorter recovery, avoid the need for multiple
general anesthetics, and reduce the associated costs.

Robotics in gender-affirming phalloplasty
Phalloplasty, a complex, multi-stage surgical procedure for transmasculine patients, aims to create a
functional and aesthetically pleasing phallus. Achieving these outcomes typically involves free or pedicled
flaps harvested from donor sites such as the radial forearm or ALT, accompanied by intricate microsurgical
vascular and neural reconstructions. Since Sir Harold Gilles performed the first successful phalloplasty for a
[37]
transgender man in 1946 , the surgical technique has been continuously evolving. In 1984, Chang and
[38]
Hwang pioneered the ‘tube-within-a-tube’ design using a free radial forearm flap , which remains the most
[39]
frequently described technique . Currently, phalloplasty is most often performed using a RFFF, but not
infrequently, ALT, pubic, latissimus dorsi (LD), and superficial circumflex iliac artery perforator (SCIP)
flaps are employed.

Phalloplasty combines the reconstructive techniques of flap harvesting and microsurgery. Inherent within
these techniques are several challenges: lengthy operative times, significant physical demands on surgeons,
and learning curves requiring high volumes of cases. Risks such as flap failure are likely to result in
suboptimal functional and aesthetic outcomes.

This section explores whether the application of robotics to phalloplasty (flap harvesting and microsurgery)
offers any advantages to standard phalloplasty in the hands of an experienced reconstructive team.

Robotic-assisted microsurgery
Microsurgery has been a cornerstone of reconstructive surgery, particularly for intricate procedures
requiring high precision, such as free tissue transfer and nerve coaptation. Robotic microsurgery is an
emerging field that combines microsurgical techniques with the advanced capabilities of robotic systems.
The proposed advantages include improving surgical outcomes by enhancing precision, reducing tremors,
and minimizing surgeon fatigue.

In 2007, the first microsurgical anastomosis was performed between the deep inferior epigastric vein and
the mammary vein during a breast reconstruction with a muscle-sparing free TRAM-flap (transverse rectus
[40]
abdominis myocutaneous flap) using the da Vinci robot . Since then, two specialized microsurgical robotic
systems, MUSA MicroSure (MicroSure, The Netherlands) and Symani Surgical System (Medical
Microinstruments Inc., USA), have been developed.

In 2024, a small study evaluating fifteen surgeons with varying levels of expertise found that robotic
assistance enabled novice and intermediate surgeons to perform microsurgical anastomoses comparably to
experts. This suggests that robotic systems may facilitate safer microsurgical performance at earlier stages of
training .
[41]

A 2024 systematic review identified only eleven studies that evaluated the role of robotics in microvascular
plastic and reconstructive surgery . Most studies had a low evidence base. Ruccia et al. concluded that
[42]