Soon after the development of Transoral Robotic Surgery (TORS) in 2004, new indications in Head&Neck Surgery began to emerge. Among these, reconstructive surgery quickly drew attention. One of the earliest reported cases involved free flap reconstruction performed by the team at Mount Sinai, New York, in 2009 (1). As expected, plastic surgeons soon joined forces with Head&Neck Surgeons (2)—everyone wanted a piece of the robotic action.
Initial research focused on the potential role of robotic assistance in free flap reconstruction. Two theoretical indications were identified:
- Flap Insetting: Robotic assistance could be used to help with suturing in the oral cavity and pharynx. However, any experienced reconstructive surgeon knows this doesn’t work well in practice. For many reasons (beyond the scope of this post), the current robots are not the ideal tools for flap insetting.
- Microvascular Anastomosis: Another idea was to use the robot for the delicate suturing of vessels. Again, in reality, this proves to be less efficient than using traditional microsurgical instruments. Performing microvascular anastomosis with the da Vinci system—or any current soft tissue robot—is not practical and offers no real advantage for most experienced surgeons.
With today’s technology, there are only two valid reasons to consider robotic-assisted microsurgery:
- Confined anatomical spaces: If the anastomosis must be performed in an extremely tight location (which is rare in head and neck reconstruction), robotic tools may offer some ergonomic advantage. Also, of course, to suture in confined anatomical spaces, like in laparoscopic surgery.
- Supermicrosurgery: This is where things get interesting (3).
Supermicrosurgery refers to the suturing of vessels smaller than 1 mm, typically with diameters ranging from 0.3 to 0.8 millimeters (very small blood vessels and lymphatic vessels, and even very small nerves). In these cases, robotic systems can offer real benefits—such as motion scaling, tremor elimination, and improved precision. Two robotic platforms have been developed specifically for this indication:
- Symani Surgical System (by MMI). See how it works (click in the image above)
- MUSA-2 / MUSA-3 (by Microsure)
Current indications remain highly specialized, but the field is growing rapidly (4). Supermicrosurgery may well become a next major chapter in robotic-assisted procedures.
We’ll be keeping a close eye on it.
J Granell. Jul 21, 2025
References
- Mukhija VK, Sung CK, Desai SC, Wanna G, Genden EM. Transoral robotic assisted free flap reconstruction. Otolaryngol Head Neck Surg. 2009 Jan;140(1):124-5. doi: 10.1016/j.otohns.2008.09.024
- Selber JC, Robb G, Serletti JM, Weinstein G, Weber R, Holsinger FC. Transoral robotic free flap reconstruction of oropharyngeal defects: a preclinical investigation. Plast Reconstr Surg. 2010 Mar;125(3):896-900. doi: 10.1097/PRS.0b013e3181cb6568. PMID: 20195117
- Brown H, Brown RA, Lenkiu L, SamSam A, Lopez J, Sawh-Martinez R. Robotic-assisted Supermicrosurgery in Plastic Surgery: A Systematic Literature Review. Plast Reconstr Surg Glob Open. 2025 Jul 17;13(7):e6912. doi: 10.1097/GOX.0000000000006912
- Imholz C, Schaller C, Watson JA, Zurfluh CE, Grigorean A, Lindenblatt N. Robotic-assisted lymphovenous anastomosis to treat periorbital lymphedema and systematic review of lymphatic reconstruction of face and neck lymphedema. J Robot Surg. 2025 Jul 12;19(1):380. doi: 10.1007/s11701-025-02552-6.