Innovative Refinements in Robotic-assisted Transoral Free Flap Inset Using Mini-pharyngotomy

Transoral robotic surgery (TORS) has revolutionized head and neck cancer treatment by offering minimally invasive access to challenging anatomical regions. The first TORS procedure was performed in 2003, using the da Vinci Surgical System to remove a vallecular cyst, demonstrating its feasibility in otolaryngology. In 2005, Hockstein et al advanced robotic applications for pharyngeal and laryngeal regions, making TORS a viable alternative to more invasive approaches, such as mandibulotomy for tumor resection. Initially used for small tumors, TORS has expanded to include larger tumors requiring free flap reconstruction for extensive oropharyngeal defects. Robotic surgery also continues to grow in other head and neck procedures, with increasing reports of robotic thyroidectomy and skull base procedures. As robotic techniques expand, challenges for reconstructive surgeons accustomed to open techniques may arise. It is imperative that plastic surgeons embrace new technology and innovate accordingly. This case series explored a novel, minimally invasive approach to transoral free flap inset and pedicle positioning using a nerve- and vessel-sparing mini-pharyngotomy. Four patients underwent robotic-assisted resection and free flap reconstruction, avoiding traditional mandibulotomy and lateral pharyngotomy, thus preserving critical structures such as the hypoglossal and lingual nerves. This method may reduce surgical morbidity, optimize pedicle transfer, and improve functional outcomes. All patients had successful reconstructions with no flap loss or fistulas, and follow-up ranged from 9 to 70 months. These findings suggest that robotic-assisted free flap inset with a mini-pharyngotomy is a safe, effective, and patient-centric alternative to conventional approaches in head and neck reconstruction.