Comparison of Robot-assisted Implant-based Breast Reconstruction Systems: Single-site da Vinci Xi System Versus SP System

We read with great interest the article titled “Comparison of robot-assisted implant-based breast reconstruction systems: single-site da Vinci Xi system versus single port (SP) system” by Kim et al.1 The authors deserve commendation for addressing such new and upcoming advances in plastic surgery to optimize patient care, comparing the da Vinci Xi and SP systems in robot-assisted implant-based breast reconstruction. We agree with the authors that the SP system, although associated with a steeper learning curve, offers several unique advantages that make it particularly well suited for breast surgery.2 The single-port platform allows the same access point to be used for axillary dissection, implant placement, and the introduction of multiple instruments, which streamlines the procedure and makes it ideal. Unlike intra-abdominal procedures, where the multiport Xi system may perform well due to the larger working space, the SP system may be optimized for tighter, more confined surgical fields such as the breast and even the abdominal wall for deep inferior epigastric perforator flap harvest.3 The primary barrier to widespread SP adoption remains institutional availability, as many centers do not yet have access to this technology. Additionally, the 2.5- to 3.5-cm incision required for the SP system may initially be perceived as a drawback; however, in breast surgery, this incision can often be necessary for axillary management regardless. We do note certain technical considerations. In particular, surgeons must be vigilant in maintaining the integrity of the inframammary fold, which might be challenging to identify with the robot. Furthermore, additional consideration must be given to avoid obliteration of the midline, which can lead to symmastia. At the same time, we anticipate that CO₂ insufflation with SP may prove less traumatic to the mastectomy flaps than manual retraction, potentially reducing flap necrosis risk—a finding supported by the lower necrosis rate in the SP cohort of this study. Finally, further work is needed to expand the indications for SP-assisted reconstruction to patients with larger or ptotic breasts, who are currently not considered ideal candidates. Overcoming these limitations will be critical for broadening the applicability of this promising approach. We congratulate the authors on their pioneering comparative study and believe their findings highlight the SP system’s potential to become the preferred platform for implant-based breast reconstruction. DISCLOSURES Dr. Bishop is a consultant for RTI Surgical and Integra and a speaker for MMI. Diwakar Phuyal has no financial interest to declare in relation to the content of this article.