Hello and welcome! We have prepared an exciting session for you. Before we begin, we want to remind you that the material shown here is the property of ASPS or the presenters. Copying or distributing the content in these presentations without specific consent from ASPS is prohibited, including screenshots, photography, live streaming and video recordings. Also, please note that this session has a corresponding forum discussion taking place right now on the PSTM 23 conference platform. If you have questions for our faculty, please feel free to submit them there. Please note that chat records may be recorded. Thank you for your participation and enjoy! Good morning! I'm really excited to be here to present an update on our robotic task force through ASPS. It's my disclosure. Mankind has tried to imitate life by mechanical means for the longest time. From the DaVinci model to the automatons to the smoking robot, robots are fascinating examples of the intersection of art and science. The major surgical breakthrough came when we intuitively launched the 2000 DaVinci robot. In 2011, robots invaded the planet of plastic surgery thanks to the extreme hard work of Jesse Selber. The global surgical robot market is projected to reach U.S. $18 billion by 2027. Advantages on robotic-assisted surgery, technological advancements, increasing adoption of surgical robots, the improvement reimbursement scenarios and the enhanced funding are expected to drive that growth. All the technology comes with a high cost and the robotic system, of course, is not different than that. Now, the surgical robot market has been segmented into laparoscopic, orthopedic, neurosurgical and other robotic systems. I would like to point out that many companies are already in several states of development. At this time, the major robotic company approved in U.S. is the Intuitive Surgical with the DaVinci robots. Of plastic surgery interest, the Simani from MMI is actively working on its approval by the FDA with possible commercialization by 2023-2024. Now, there are many studies showing the benefits of robotic-assisted surgery in several surgical fields, but there is no FDA approval for plastic surgery procedures, which creates many barriers for its use in our field, despite the increased interest. So, given those barriers, we established a task force to address and overcome some of these issues. We are part of the SPS Technology Committee led by Justin Sachs, and we have a great group of people really engaged to push this technology forward. So, the goal of our task force is really to evaluate the current status, challenges and opportunities to incorporate robotic technology into plastic surgery, covering a range of factors such as regulatory hurdles, education, financial considerations and the potential for a broader adoption of the technique in our field. Currently, robotic technology is used in plastic surgery mainly for head and neck procedures, breast, pelvic reconstruction, repair of rectus diastasis done by general surgeons, by the way, microsurgical anastomosis, lymphatic surgery and peripheral nerve surgery. We recently completed a survey that will be sent out to members of the SPS to actually gauge their interest in robotic plastic surgery. So, the major roadblock that we face right now is certification for robotic procedures. Intuitive has not shown any interest in supporting plastic surgeons, and there are a few reasons for that. Just to summarize, their claim is that it would require an FDA approval, and right now they're not willing to spend the time and the money to start an IDE process for a future 510K application. Now, with technologies coming into the U.S. market, we have a unique opportunity to explore the feasibility of a precise certification process tailored to the field of plastic surgery. We would like to ensure that this certification remains platform agnostic. And to achieve this, we will need to define credentialing standards and criteria for plastic surgeons surrounding both robotics and traditional open techniques. Our central focus is to prioritize safety within the hospital environment. We believe that that would allow us to standardize robotic procedures and hopefully integrate them into the resident's training in the future. Now, given that many of us do not meet the stringent criteria set by Intuitive for training, obtaining credentials in robotic poses significant challenges, as you can see here. Hospitals are increasingly mandating robotic training as a credential requirement. And to address these challenges, what we propose is a shift in hospital policies, advocating for greater collaboration with colleagues from general surgery, colorectal surgery, and gynecology and obstetrics who used robotic procedures. We believe that if we have their support, we can work closely with the hospital administration to drive policy changes that will better accommodate the evolving landscape of surgical technologies and training needed in the future for plastic surgery. Now, our strategic approach really involves several key elements. We continue to work with the Intuitive leadership to address our training challenges. Maybe there will be an opportunity with their new DaVinci SP coming into the market as the SP is the robot that they are trying to market for mastectomies. Now, we are actively seeking collaboration with the American College of Surgeons, focusing on quality and safety, while also engaging with other specialties to explore collaborative opportunities and to avoid potential conflicts that could happen with us using robotics technologies. Now, we are committed to preserve the culture of innovation within plastic surgery and proactively prevent the creep of other specialties into our domain. As I mentioned, the robots are very much an enabling technology and everybody can use it. Next, we plan to develop a curriculum for plastic surgery, along with certification centers of excellence for robotic training. Now, our ultimate goal is actually the seamless integration of robotic surgery into plastic surgery training. While some of the U.S. centers currently provide robotic training as part of microsurgical fellowships, our vision is to work closely with our RC and ACS to develop robotic surgery curriculum that allows for robotic surgery exposure earlier in the residency programs. We believe that's the ultimate goal. This proactive approach aims to equip residents with valuable skills and opportunities for future certification if they wish position them at the forefront of technological advancements in plastic surgery. Now, stay tuned because this is going to be a long path, but I think it's a very fulfilling one. At this moment, we are writing recommendations for ASPS and PSF regarding educational resources, practice management, in order to support the evolution of robotic technology in plastic surgery. You will see on your email an ASPS survey in robotics. Please complete that if you can. It will be very helpful for us to bring that forward to the companies and say, hey, we can do this. We are very excited about robotics in plastic surgery. And there will be an integration of robotic deeps to the PSF registry in the future as part of the PSF GIP registry. We're not there yet, but we hope to notify everybody when that happens. Thank you so much for your time. And that's all I have to say. I'm happy to respond to any questions. Hi, my name is David Currowander, and I'm going to talk about starting a plastic surgery robotics program. I have no industry disclosures. The most important disclosure, though, is that this is a single surgeon's perspective. Others around the country have had widely variable experiences starting robotics programs. And also, this talk largely relates to use of the robot for minimally invasive flap harvest. Others have used the robot for microvascular anastomosis, which is important, but I have no experience with. Our objectives today are to discuss how to build a robotics program and describe the challenges. I believe there are six critical building blocks for a successful plastic surgery robotics program, and we will go through each in detail. The first is education and awareness, and by that I mean among plastic surgeons. Plastic surgeons need to learn what the robot can do, how it may help patients, and if it fits into their practice. I'm probably preaching to the choir here because you all chose to tune in, though. The ASPS robotic task force has a goal to promote robotics and plastic surgery through various means, including several plant panels here and at other conferences, publishing outcomes, collaborating with industry, and exploring issues related to ASPS member interests, reimbursement, areas for growth, and addressing practice creep from other specialties. How do you train to use the robot? This is one of the biggest hurdles. There are two scenarios. How can residents and fellows train to do robotic surgery, and how can those already in practice train to do robotic surgery? For perspective, I did integrated plastic surgery residency at Case Western Reserve University without any specific robotic or laparoscopic training. Then I did the MD Anderson Microsurgery Fellowship and was lucky to train with Dr. Selber, who has trained many of us doing robotics in practice. And now I'm at Rush, which has a strong robotics program across many specialties and has supported me. A handful of residencies and fellowships offer robotic exposure, including our microsurgery fellowship at Rush, which I will shamelessly plug here. But the future needs to move toward a formal curriculum, and the ASPS robotics task force is working on a curriculum similar to the one residents and other specialties follow with required modules, bedside assistant cases, and console surgeon cases. Also, opportunities may exist by rotating with other specialties when plastic surgery volume is insufficient. Simulation is unbelievably helpful for this. It is very lifelike. Many centers have a da Vinci simulator, although there are no specific plastic surgery modules for this. You can see some images from the simulator here. For those already in practice, the pathway is somewhat less clear. This is going to require coordination between societies to define a clear pathway, including coordination between the ASPS and the American College of Surgeons, as well as industry, to establish training programs, courses, and criteria. Requirements are highly variable for credentialing between institutions. I firmly believe that it is best if the plastic surgeon is harvesting the flap. But in the meantime, the robotic part can be accomplished with collaboration from experienced robotic surgeons from other specialties. Again, I strongly believe we need to be on the console harvesting the flaps. It's not ideal to have someone else raising your flap, but it may be appropriate in certain situations. And for now, nobody will stop you from honing your skills on the simulator. Institutional support. At my institution, there are defined criteria for robotic privileges, which are universal regardless of specialty, and include evidence of device training, evidence of cases in training, proctored cases, and an annual review of outcomes. The OR also has to be supportive, and this includes robot availability, which can be challenging. The OR team also has to be capable of doing both microvascular and robotic cases. We chose to cross train the micro scrub techs and circulators to do robotic surgery. Additionally, a good bedside assistant is very helpful. Colleague support is critical. The partners and your higher ups need to be supportive. My micro partners are pictured here. We co-surgeon most free flaps and these partners need to buy into the benefit of the robot. And they also need to support you as you go along the learning curve, which can be significant. Also experienced surgeons at the institution who do other who are from other specialties is essential. What I stress most about honestly is getting into the abdomen and taking down adhesions. And if I have any concern whatsoever, I call one of these people who are GYN, general surgery, and colorectal surgeons to help. It's always helpful to have plastic surgery mentors experience with robotics. John Shuck, Jesse Selber, and Dan Moraro have helped me from a distance offering advice and pearls for new scenarios that I face. In my practice, I consider the robot for deeps and robotic APR reconstruction. So who's a good candidate? My first patient was a CrossFit athlete. She was radiated, had concerns about abdominal morbidity, but also wanted to get rid of her excess abdominal skin and some fat from weight loss. And patients want to tell their stories. The media likes these stories. The hospital likes these stories. You can see a few of them pictured here. If I use the robot for deep flap harvest, I'm going to have a safe, successful surgery with maximal benefit. Pick the home runs first. Convince your boss, your partners, the OR, and most importantly yourself that you can execute the operation and it's worthwhile. For me, these home runs are patients with a high, large, single perforator where the robotic approach, unlike the open approach, will spare crossing the arcuate line. And unilateral cases may get much lower pressure. We looked at how common this favorable anatomy arises on CT angiogram. 71% of patients have at least one suitable hemiabdomin. And to give you a sense of the benefit of the robot, the red line in this photo, labeled with the letter A, is the expected robotic harvest fascial incision. Line C, the yellow line, is the expected open harvest, and the green line, B, is the estimated fascial incision that can be spared, the difference between the two lines. There is a learning curve, and I am definitely still on it. The robotic deep takes me longer than an open deep. Dan Marrero and Andrea Marrera have data that it takes about 17 robotic deeps to eliminate that curve. For now, I feel it's important to do all the steps myself to become comfortable, so here I am docking the arms, dissecting the pedicle with one of our fellows, and here is the pedicle extraction through a small fascial opening. Extract the pedicle. Got a video going? All right. Okay. And here's one patient photo with a small fascial incision. Our colorectal surgeons do a great job sparing the pelvic floor and taking a narrow pelvic margin, so robotic rectus is rarely indicated in my practice, although it does come up occasionally. I use it for robotic APR that has a large dead space, and here you can see the small robotic incisions in the perineum after a buried rectus flap. Outcomes review is important. With any new technology, we need to evaluate its safety and efficacy at a multi-institutional level. Each case, we use this template, which was created in Pittsburgh, and there are plans for a multi-center database through the ASPS to track outcomes. At our institution, we require annual review of cases and outcomes to maintain privileges. So far, I've done three robotic deeps and one robotic rectus for APR in two years of practice. None were converted to open, and there were no major complications. This is about 10 to 15% of potential cases and limited by a number of challenges. So what have been the biggest challenges? I did not have the volume to consistently get robotic block time. We now have flexible robot add-on block time, which has been very helpful. Scheduling is a challenge. Typically, we use a co-surgeon model for free flaps that allows for flexibility to be in two rooms in the same day. However, for robotics cases, I have to block off an entire day, as no one else can move the case along except for me. There is a learning curve. It takes longer to do these cases at first. And the patients, the more deep flaps you do and see, the more chance you have to make them robotic. For me, breast cancer is only about 30% of my practice, which is more heavy in extremity and sarcoma reconstruction. Thank you to Dr. Morera and the Robotic Task Force for inviting me to speak. This is my email address and cell phone number. Please do not hesitate. Reach out anytime if you think I can be of any help. My name is Scott Levin from the University of Pennsylvania, and I'm delighted to participate in the panel, The Rise of the Machine, about robotic surgery. And I'm going to talk to you about an evolution in technology in reconstructive microsurgery. These are my disclosures. And what is pertinent to this talk is that I serve as a consultant to MMI. Robotic surgery in plastic surgery is here to stay. At this year's 69th Annual Ivy Society Scientific Meeting, a paper was presented from Penn State University entitled Robotic Assisted Surgery Training in U.S. Plastic Surgery Residency Programs. So it begs the question, when and how will robotic microsurgery and robotic surgery training enter into our curriculum for our residents? It's here already. In fact, the ASPS has set up a robotic task force, technology committee, organized by Justin Sachs and Peter Rubin, and several people from around the country, such as Jesse Selber and Risa Al-Dahan, Rich Bayonosa, Andrea Marrera, and others from around the country have been working in this space already using the DaVinci robot. The history of microsurgery is fascinating and dates back to the Dutchman Zacharias Janssen, who using two lenses created a magnification of 20 to 30 times. This was in early 1600s. This was followed by Robin Hooke's work, adding a third lens and could magnify objects up to 275 times. And we fast forward to the introduction of the operating microscope that we use today, first popularized by Julius Jacobson. Before there was microvascular surgery, the principles of vascular surgery were formulated by Correll and Guthrie, ultimately resulting in Alexis Correll winning the Nobel Prize in 1912. While his principles hold today, Correll was discredited as a Nazi sympathizer during World War II, and much of his recognition was rescinded because of that activity. Julius Jacobson was a vascular surgeon from Vermont who moved to New York City, and in 1960 with co-author Suarez in SGNO, described anastomosis of a one millimeter vessel using the operating microscope. And this ushered in the era of modern reconstructive microsurgery. Bernard O'Brien from Melbourne, Australia, was a pioneer in reconstructive microsurgery in the late 60s and early 70s. And his classmate in medical school was Gerard Kroc, a famous ophthalmologist in Australia, who showed Dr. O'Brien the tools and the instruments that he used in ophthalmology, and they rapidly became translated into reconstructive microsurgery at St. Vincent's Hospital. This is a picture of Dr. O'Brien doing the groundbreaking for the O'Brien Institute dedicated to reconstructive microsurgery. I had the privilege of studying with Robert Acklin, who was in Louisville, Kentucky, when I was a fellow with Harold Kleiner in the late 80s. And Dr. Acklin popularized the use of the operating microscope and was a pioneer in the anatomy and physiology of free tissue transfer. He's pictured here with Gene Tritt and Werner Springler from the S&T Company, and along with Victor Meyer, who was president of the World Microsociety, when this photograph was taken. And this recognition was for the work that Tritt and Springler done to fabricate small sutures that we use today. The emphasis on anatomy is something that I learned from Bob and is a hallmark of learning new flaps, discovering new flaps, and advancing reconstructive microsurgery. This is our human tissue lab at the University of Pennsylvania. Reconstructive microsurgery, as we know it, has been performed for over six decades. And initially, the first era was only replantation. And in 1973, first free tissue transfer was done by Ian Taylor from Melbourne. And in 1998, the first vascularized composite allotransplant and arm transplant was done by Max Dubernato, a New Zealand prisoner. So there are three eras, and throughout the last six decades, our technology, our magnification, our imaging, our ergonomics have all improved based on the evolution of technology in reconstructive microsurgery. This is a patient I treated more than 20 years ago that underwent a scalp replantation using a conventional operating microscope and probably 10-0 or 11-0 suture at the time with conventional microsurgery instruments. This is the appearance of the scalp replantation immediately post-operatively and I recall this case that perhaps at finer instrumentation such as super microsurgery instruments may have been helpful at the time, but they were not available. This is the result of this patient's scalp replantation at one year and the power of microsurgery I think is well illustrated by this case. In 1982, I was an intern in the Department of Surgery at Duke University Medical Center. Dr. Randy Chitwood was my chief resident, and Dr. Chitwood went on to have an illustrious career as a cardiothoracic surgeon and was a pioneer in robotic heart surgery, and he's going to tell you about his early experience. Scott, thank you so much for asking me to make a few comments regarding my journey in surgical robotics, and it's been a fantastic one. It started in the mid-1990s when I had the notion of operating through tiny incisions to do mitral valve repairs. As you can see, I'm sitting at the prototype of the dementia device in 1997. It was a real eureka moment, because I knew this was disruptive technology. However, the device was clunky, the vision was poor, and it had to go a long way before clinical application. Then, in 1999, we bought the first device in the United States in preparation for the FDA trials. In the year 2000, under an FDA IDE trial, we did the first dementia mitral valve repairs. You can see here. Of course, our patient did very well, and you can see an image of her. She's giving me permission. At that time, she was 63 years old, and now she's 92, and I spoke to her last week and she's doing quite well. This was just the beginning of what you're doing now with microrobotics to anastomose tiny vessels and tiny lymphatics. Now, the idea is this is true telepresence. You have dynamic vision, great magnification, high-fidelity ergonomics, which filters all the tremor that we have. This will go very far in your specialty, and I believe will be the new horizon for where we're going with microsurgery. If we look forward, the next era of reconstructive microsurgery will include the techniques and execution of super-microsurgery, popularized by Asao Koshima from Hiroshima, Japan, the continued development of lymphovenous anastomosis, and the utilization of robotic instrumentation for diminishing tremor, increasing accuracy, and facilitating anastomosis of smaller and smaller vessels. As we evolve into doing perforator-to-perforator surgery, lymphovenous anastomosis, are there technical limits to what the human hand and brain or hand-eye coordination can accomplish? And instrumentation has changed, suture size has changed, surgeon's ability may be at a certain limit, and is there now a race to the smallest caliber of vessel that can be co-opted? Dr. Koshima even talks about nano-microsurgery, which is far into the future. The award-winning author Michael Lewis wrote a book entitled The New New Thing, and this was about the life of innovator and pioneer and billionaire Jim Clark, who started the company Netscape, developing computer chips for digital technology and the computer age. I would say that robotic surgery is the new new thing in the field of surgery, and robotic microsurgery is evolving in reconstructive microsurgery as the new new thing that has tremendous promise and merit to advance our field. One could argue that as our technology improves, our visualization and optics improve, that there are no limits to microsurgery, especially if we utilize machines and robotic technology to perform our work. This is an infant with an atretic thoracic duct that underwent lymphovenous bypass as a life-saving operation performed by my partner Stephen Kobach at the University of Pennsylvania and Children's Hospital. The lymphovenous anastomosis is to the left, and on the right you can see the dye flowing into the subclavian system after the anastomosis. Theoretical and practical advantages of using robots in microsurgery include improving anatomic access to hard areas that cannot be reached with the human hand, the fact that they are motion dampening and eliminate the effect of tremor on execution of suturing. The robots themselves are designed to have finer instrumentation for holding smaller needles and for some surgeons it could be the rebirth of their microsurgical career because of technical challenges that have prevented them from performing microsurgery. And for the aging microsurgeon, the tremor reduction and dampening might extend their careers because of the decline that many surgeons have in technical ability. This picture just illustrates the size of the robotic wrist compared to a finger pulp and the fineness of the needle driver that's capable of holding a 11 and 12-0 suture quite easily. This video is an example of the robot manipulation in the passing of a needle. These three videos demonstrate the manipulators hand-held in the middle frame, the robotic arms working, and an in vivo example of robotic microsurgery performing an anastomosis. The Somani robot has been utilized in Europe and more than 280 cases have been performed so far in centers in Europe. The FDA has not cleared the robot for utilization in the United States but hopefully this will be available in the first quarter of 24. These include free flap cases, lymphovenics, anastomosis, and microneural surgery. The microsurgical robot for anastomosis can be used with advanced operating microscope technology such as the 3D exoscope that is pictured here. Dr. Marco Innocenti, who is chair of the Department of Plastic Surgery and Orthoplastic Surgery at the Rizzoli Institute, in Bologna, was one of the first pioneers of robotic technology in microsurgery in Europe. This is a case of Professor Innocenti's, a free tissue transfer performed to the foot using the robot for microvascular anastomosis. The video here demonstrates the view from the microscope using the robot and the fact that there's a viable free flap at the conclusion of the case. The robot has been used in cases such as this head-neck cancer pharyngeal reconstruction, as well as perforator-free flap reconstruction, and again in a case to the foot and ankle. Here you can see the robotic setup and a successful free tissue transfer. In preparation for FDA clearance of the robot, we've set up a robotic microsurgical training center for our residents and faculty and for others from across the country to come and be trained so that clinical execution is done with competency and understanding of the principles of robotic microsurgery and executed safely. I've shared with you the history and evolution of microscopy, the introduction of the operating microscope, the evolution in reconstructive microsurgery, and what the future may hold. And as we move from standard robots such as the da Vinci to specific robots for microsurgical anastomosis and ultimately flap dissection, the opportunities in reconstructive surgery and reconstructive microsurgery will expand as they've done over the last 63 years. Thank you. Tonight, I'm joined by my co-moderator, Dr. Neil Tanna from New York. And we're going to be speaking, my name is Justin Sachs, and we're going to be speaking about the rise of the machines. Should we be afraid of robotics and plastic surgery? And we have five panelists tonight, Dr. Scott Levin, Dr. Jesse Selber, Dr. Andrea Morera, Dr. Graham Schwartz, and Dr. David Kurlander. And we will be asking each individual questions individual questions about these interesting topics around robotics and plastic surgery, and even artificial intelligence. So with that, Dr. Scott Levin, my question to you is looking towards the future, how do you envision robotic surgery evolving within the realm of plastic surgery over the next decade? And now, are there some innovations or technological advancements on the horizon that you believe will revolutionize specific procedures or the field as a whole? Justin, thank you. My name is Scott Levin from the University of Pennsylvania. I'm Chair of Orthopedics here and Professor of Surgery in the Division of Plastic Surgery. And I think many people know I'm keenly interested in surgical history. And if we look at the history of robotic surgery, robotic technology is in OBGYN, it's in urology, it's in cardiac surgery for valve repair. The evolution of surgery has gone to less morbidity, minimally invasive surgery, and robots are used in orthopedics for hip and knee replacement. They're used in spine. So the question becomes, where will we or where can we use robotics in plastic surgery, in reconstructive surgery? And my esteemed colleagues, people like Dr. Morera, Dr. Selber, particularly Rich Bayonosa out in Las Vegas, have already taken the da Vinci robot, which is well established, and are doing work in the abdomen and in breast reconstruction with the robot already. So the robot is here, let's say version 1.0. As many know, robotics are also being applied to smaller and smaller vascular structures. The LVA evolution around the world has made a difference in breast surgery, in chronic lymphedema, and the ability to technically anastomose vessels the size of 0.3 or 0.4. I challenge that there are very few people in the world that can do that with hand-eye coordination and conventional microscopes. So not only have we seen an evolution of robots that can dampen tremor, that can be precise positioning instruments for the 11.0 and 12.0 sutures for LVA, but they also couple with amazing evolving technology in microscopes, the exoscope version 2.0 and 3.0 exoscopes, the improved optics and magnification and resolution of newer and newer microscopes. I mean, I've been doing reconstructive microsurgery for almost 40 years going back to my residency, and we see continued generations of microscopes and now coupled with the ability to do robotic anastomoses, I think, Dr. Sachs, we're going to see continued innovation. I know that's an overused word, but continued development of the application of the robot. I'll give you a keen example. Many plastic surgeons around the world in microsurgery, forget about free flaps, forget about LVA, are involved in living donor liver transplant surgery. The plastic surgeons not infrequently do, as we do here at Penn, Steve Kovach and I, Saeed Azuri, we do the hepatic artery anastomoses in children and adults. We're deep down in the abdomen, the diaphragm is moving, it's technically challenging, and yet we get it done with long instruments and lots of experience with a very high success rate. That being said, the wheels and the gears are turning that I think continued robotic technology can be applied in microsurgical situations like that, even in intra-abdominal, for example, anastomosis with a robot. The robot potentially has the ability for people who are technically challenged or fearful to do microsurgery because of the anastomosis itself. This may hold promise. The evolution of renewed interest, we hope, in replantation surgery because the robot can be used for small vessel anastomosis. I think the future is bright. What do we do as plastic surgeons? I think if we look at the history of microsurgery, is man going to be replaced by machines? Man's brain won't be replaced by machines altogether and somebody else is going to talk about AI, but I am an aging microsurgeon. I am an aging microsurgeon. My hands are still good. This is self-disclosure, Dr. Sachs. I did a perforator-to-perforator anastomosis today in a medial geniculate artery flap. We finished a few hours ago off the radial artery. Yes, I did it conventionally with 10.0. Maybe I would have liked to, or maybe in a year or two or five, I need the robot. I want to keep going, but my hand-eye coordination and the evolution of tremor, which has been well studied in the aging population, I may be precluded from doing that with conventional microscopes and handheld instruments. You give me a robot and maybe like DeBakey or Denton Cooley, I'll be operating and doing free flaps into my 90s. I'm being facetious. I don't plan on that. You hit the point right on the head. Yeah, so my concluding statement is, I think we're going to see an evolution of robotic surgery in plastic surgery. This will be no different than the concepts of laparoscopic cholecystectomy, endovascular work, endoscopic procedures, minimally invasive. It's all under the domain of technology advances, our cause in all of surgery. I think there'll be tremendous opportunities in robotic microsurgery. We didn't touch on, but this is evolving, the ability to do even robotic dissection of perforators and our perforator flaps may be facilitated by evolving technology that I'm familiar with in robotic microsurgery with additional tools that are the extension of man's brain, but with small hands that are more controlled and can be more precise. Thank you. Yeah, Scott, incredible, incredible response to the question. And while you were speaking, I wanted to ask you about the hepatic artery anastomosis, and you hit it on the head, because that is the operation that requires augmented tactile feedback, and that's exactly the kind of places that we will innovate in. It'll make us better surgeons, and I agree with you on that stuff. Have you done a robotic assisted hepatic artery anastomosis at Penn yet? No, no, because the FDA has not approved the Somani for U.S. use. As a matter of fact, there are no robots, and Penn has a, we stood up a robotic training center here. Many of my colleagues around the country have been here working with the robot, and as soon as the FDA releases it, we'll go to the cadaver lab, we're going to open an abdomen, we're going to practice an LDLT, living donor liver transplant, and I hope to next summer be telling you that we did this. Outstanding. Dr. Tanna. All right, so we're going to turn it over to Dr. Jesse Selber. You know, I'm very fortunate to be kind of involved in this space and this panel because of Dr. Selber. You know, he is really, you know, everything I've learned is from him, the technique I use is from him, and it's a two-part question for you. You know, the real thing is that I heard you speak over a decade ago, and I was one of the critics who thought this was, you know, marketing or trying to find something, you know, in retrospect with the machine, and the reality is you were clairvoyant. You saw something back then. So, let me ask you, why did it take a decade for us to come to this realization? And you look across the country, there are more and more plastic surgery units and centers who are adopting robotic surgery, whether it's for upper extremity surgery, breast surgery, you know, where do you think that resistance was? What do you think was the reason why it took this long for it to spread like this, this wildfire spread? And then the second part is because you've demonstrated the ability to, you know, see forward, is where do you think it's going to go, especially with things like artificial intelligence? So, if you can sort of give us that perspective, it would be, you know, I think very helpful for the viewers out there. Yeah, thank you, Neil. First of all, you've been a wonderful pupil, and Neil picked up the robotic deep in a matter of three days that we spent together and has charged forth since. I'm extremely proud of the work that you're doing. You know, when I started working on this, I think your comments are right. I was a little bit of a hammer looking for a nail, and I developed applications that were not necessarily transferable or generalizable to other physicians who maybe spent less time on the machine or less familiar. When I look back on it, you know, Bill Gates always says you overestimate what technology will do in two years and underestimate what it will do in 10. And I felt that, you know, we were at a tipping point many, many years ago and never arrived there. And now, you know, it's interesting because I gave my first talk, as you said, in 2009 at the association. And in 2023, at the WSRM in Singapore, there were 24 talks on robotics. And it's just absolutely amazing how this has exploded. And it's not exploded because of me or anything or any one individual. It's exploded because the adopters and the technology curves have caught up. And, you know, the emerging market has emerged. The emergence has come. And I think the combination of minimal invasiveness and the diaspora of new and different robots and the clear benefit of a particular application, and for that, I point to the Robotic Deep, where we have truly solved a clinical problem that has existed in the state of the art of that operation for 25 years. And, you know, if you do this operation right, you eliminate that risk. And that is meaningful for an operation that a lot of people need. The slow to adopt, I think, is a natural conservatism, an inavailability of training pathways, a regulatory environment that is not conducive to new learners, and our educational pathway as plastic surgeons, which has become integrated and taken away the natural robotic training that general surgeons now learn just as a matter of course. The more interesting part to me is the second question you asked, which is where is it going? And this is, you know, the title of the panel is Should We Fear Robotics and Plastic Surgery? And I'm going to put this into two categories. I'm going to put this into the little F fear. And the little F fear is, you know, our robotics can be able, our robots can be able to do things that we can't in the operating room. And should that hurt or should that wound our swollen pride? And then the big F, the capital F is, you know, will artificial intelligence be the end of humanity and human intelligence as we know it? And that is the fear that actually I think is far more interesting, and far more concerning. And let me just say a little bit about both those things. So the fundamental thing that allowed, that is the major change that people don't recognize in robotics is placing a computer in between the human hand and the patient. And so that's what the da Vinci did. That was the step beyond laparoscopy, right? A computer in between you and the patient. And that seemed benign for a long time because we were essentially in an operator effector world. Artificial intelligence really hadn't gathered all that much steam. And so that computer, all it did was translate our emotion into smaller motions or more precise motions. And that's a lot of what we do with robotics. And that's the little F, you know, can the robot do it better than our human hands? That's the John Henry and the, you know, and the steam engine phenomenon. And that's, I think, an easy question to answer. Yes, the robot will be better. Yes, it will be guided by human hands or human brains in whatever form. Where I differ from Scott is I don't believe that the human brain ultimately has primacy here. There is very little in human history that gives us the impression that less intelligent things will govern more intelligent things. And Elon Musk has said that we will represent a very, very small percentage of Earth's intelligence in a very short period of time. And that computer that exists in between our hands and the patient, to go back to that part of things, is getting smart. And it's learning based on pre-recorded videos. And all AI really needs is high density source data that's grounded in truths, and it can go from there. And so the source data is the video. And Intuitive, if you want some evidence of this, has already launched a program called Insights. And what Insights does, I hope I'm not giving away intellectual property here, but what Insights does is it gives nudges, it gives nudges to the operator about what they could do better. So you're not supinating your wrist enough on a throw, you're not clutching enough when you move your hands, you should get closer with the camera if you wanna see that better. So it's already able to direct that into the console and give you that information in real time. There's a very short stretch of road between it knowing what you should do and it doing it. That's, I think, fairly uncontroversial. So I think the little F is, yeah, should we fear robotics in plastic surgery? Absolutely, just like we should fear any technology that has the capacity to be more intelligent and precise than us. I think the capital F is we should fear truly the end of humanity and human intelligence at the hands of greater intelligence than our own. That's probably too lofty for this whole thing. If you want something more plastic surgery oriented, I'll fire away, but let me just stop there and let you- Jesse, I'm just gonna jump in for a second there. I agree with some of the comments you made in the limit. So if you take things out in the limit over time, especially with what's happening with self-driving, like they're pumping photons in and they're putting out action. So they're studying the mechanism of the way people drive so that they can do the same thing for surgery, but you need to do this for like millions of hours. And then the question is, still will the computer be able to map every potential outcome and then beat a human? So they study this in chess. They show that the best chess players were the ones that partnered with the computer. So the groups of people that partnered with the best supercomputers had the best outcome. So I kind of pushed back a little bit, at least in the next decade or two, that humans working with robotic assisted surgery might be better than the actual robots because I still think there's a lot that can go wrong in between that time, but in the limit, and if you say like a thousand years, maybe you'll be correct. Well, let me just, let me give you a quick concrete version of this. So I think the way this is going to roll out is in gated tasks. So you mentioned an interaction between the human and the chess playing robot. I think this is how it'll work, right? So there's short task algorithms like pick up a needle, place a suture, tie a knot. Those I believe will be short autonomous tasks that a robot will be able to perform autonomously gated by humans. So you'll sit there and say, okay, proceed to step two, proceed to step three, proceed to step four. And it won't be this kind of rangy machine making judgments in real time and making those sorts of decisions. I do want to say that the timeframe that you've laid out of a thousand years, you know, it doesn't take thousands of hours to train these models. They go from 1 billion examples to 10 trillion examples in a matter of hours. And that's really the power. And that's the thing that you can't turn off and we can't- Well, all I said is in a thousand years, robots will be doing surgery, but I didn't say it won't happen in a decade. I just said in a thousand years, in the limit. Graham, do you ever want to respond to that question? Yeah, no. I think these are really intriguing. These are intriguing points. And I think that whereas, I think I fall somewhere between the two of you guys. I think, you know, Jesse kind of brings up this existential question, right? Which is pretty scary to kind of think about. But I think in the context of surgical robotics, you know, I think what is another kind of really important point is kind of the concept of situational awareness, right? And yes, you know, I think that we're not far and it's been demonstrated at least, you know, in studies, in the lab, in vitro and so forth. And even in some cases in vivo where these, you know, these subtasks can add up and sort of create some level of autonomy, right? But there are various varying levels of autonomy from, you know, sort of a very low level where we're kind of just, there's a master slave kind of situation, which is what the da Vinci is, right? Doing robotic telesurgery to something where, you know, at Johns Hopkins, they developed a kind of a fully, or I shouldn't say fully, but near autonomous, you know, robot that can perform an intestinal anastomosis, right? And improve on some metrics over and above, you know, skilled surgeons. So while I think that we're going to see these subtasks kind of come to play, right, in the sort of more immediate term, we're not really going to be able to integrate all of the huge variety of data sources and data streams that we have sort of in our clinical milieu, right? The EHR, all of the sensors, the devices, you know, the interactions of the team, the patient, you know, and put that together, you know, with our robot. And I don't think we're there just yet, maybe 10 years. You know, I'm not, I don't think that that's possible in the next two years or three years. But, you know, to have that awareness of the patient's specificity, what's going on with their history, like what do we have to, you know, how do we, how am I as the robot going to position myself and my arms, you know, in order to deal with, you know, all these types of things? Is there a bleeding event? On and on, these sort of situational and situational events and, you know, the need for sort of awareness in the context of the situation at hand. Can I ask a question to both of you since you're all extrapolating? I'm so existentialist like you, Jesse. I think we're going to be all be, we're going to be overcome by robots in the future, but that's not the question that I want to ask. What I want to ask is, do you guys see, you know, with robotic surgery, if we can coordinate VR and IR and help to decrease health, you know, disparities around the world? And I think there's a lot of emphasis on that. And I think it's a technology that can potentially, you know, enable a lot of us to be able to do that. I would love to hear your opinion. Yeah, happy, happy to provide it. So I think, you know, this is an interesting question because some of the early robotics were done overseas. As you know, one of the first robotic operations was a transatlantic cholecystectomy. So that capability has been around for a long time. And of course, the DaVinci technology was developed by the military to work in near space and forward areas of combat. So that was always the plan. And I think that, you know, still has the potential to democratize some surgical technology into developing countries and so forth. You know, there's still the issue of maintaining the core competencies at a site required to deal with the machine. I don't see that promise unfolding immediately. What I do see in the IR and VR world is something that we haven't really fully taken advantage of in robotics here, even in our own milieu, which is augmented reality. So we have the ability to see much, much more than is available to us with our own eyes. We can see blood vessels, we can see lymphatics, we can see potentially histopathologic staining, and we can toggle back and forth between those and ways of navigating and navigational systems that get fed to us. And I think those sorts of augmentations, just like when we sit in the car and look at a map on a screen that's giving us a navigation, I think that's really an underutilized set of competencies that the machines have. I'll just pause there. And not related to robotics, but I have a DIP flap on Thursday. I have a CT scan, which I converted to a DICOM file. DICOM file is uploaded to a server. I put on last night my helmet in the virtual reality. In 30 seconds, without looking at the CAT scan, I already know where the perforators are going on the right side. I already have a visual plan of what I'm gonna do the operation on Thursday, without even looking at the CAT scan at all. So that's- So what the ortho robots are doing is you don't look at that DICOM file. That DICOM file gets uploaded to the robot. The robot performs the machine based on stereotactic guidance. So we're already in that world. Okay, Graham. It's much, much easier in bony surgery, much, much easier. And it all gets down to sort of registering that image. With soft tissue surgery, like what we do, it's really, I think that actually is one significant application of AI machine learning as we move forward in this space. Because the only way that we're gonna be able to model sort of deformable soft tissues is using sort of these machine learning techniques. Okay, so great, great discussion so far. We're gonna go on to Dr. Andrea Moreira, who I'm gonna ask the next question and then she'll introduce herself again. Given the precision and capability of robotic surgeries, which specific procedures within plastic surgery have you found the most significant advantages over traditional techniques, particularly breast reconstruction and lymphedema surgery with the robot? Andrea. Yeah, thank you. Andrea Moreira, University of Pittsburgh. I, so the procedures that we have, you know, longer case series and more statistics significant data is actually autogenous breast reconstruction with a GIP-free flap. And kudos to Jesse, without his idea in his forefront, you know, view, we would be doing this, probably it would still be delayed. And lymphatic surgery, for sure. For the GIP, the major advantage of robotic surgery is that you're causing less damage, not only to the muscle, but also to the fascia. So you denervate that muscle in a much less percent than what you do with an open case. So if we have a risk of hernias and bulges for five to 10% in a traditional GIP, you're gonna decrease that probably to the single digits with the robotic GIPs. And that is something that all of us are working on long-term data right now. So for robotic GIPs, I think the application is there, the patients recover faster, they take less opioids, and hopefully we'll be able to demonstrate that over time. Now, lymphatic surgery, I mean, we just had an amazing panel at WSRM actually, and one of the plastic surgeons from Germany presented her lymphatic reconstruction of the thoracic ducts in babies with the Simani robot. So for lymphatic surgery, I think the use of the Simani or maybe the Musa in the future, I think it will totally revolutionize that kind of procedure. It's not an easy surgery to do. It does require a lot of attention. If you're doing several LVAs, and Grant can probably comment on that, you become very tired at the end, and the robot eliminates a lot of those issues. So I think at this point, definitely lymphatic surgery and breast reconstruction, for sure. I would love to see if anybody else has any other fields in plastic surgery that we can see robotics being used. And then pelvic reconstruction, of course, because you have the VRANs. Because it's such an enabling technology, I wouldn't be surprised to see general surgeon and colorectal surgeons doing their own flaps over time. So I think it's really important for us to have that discussion right now. Yeah, so how do you go about getting robotic privileges? So we're dealing with this now. So Lucy comes on, they have general surgery board training, their plastic surgery training, and they wanna get robotic privileges, but they haven't done the robotic cases as faculty. What are the barriers? And what's the best path forward to get robotic privileges in an institution? Right, so that's gonna vary according to if you are fully, if you're board certified in general surgery and plastic surgery. So let's say you went into an independent route, or if you went through an integrated route. If you did your general surgery during, I don't know, the last 10 years, 15 years, and you had experienced with the robot. Nowadays, the certification process and the credentialing process asks you to do 20 cases during training as the surgeon. And then you have to have five proctored cases. Usually you do that during your general surgery residency, your program director will write a letter. And with that, you can go to the company and get your certification, right? This is if you graduated in the last five years, that's the route. Now, if you graduated a long time ago and you were not exposed to robotic surgery, but you did your general surgery and you had laparoscopic training, you can go to your hospital and be proctored. By two or four cases by a certified surgeon in your hospital. And then they can give you a letter and say that you're capable, and then you can go and get the certification. Now, for integrated residents, it's very difficult. And I tend to think that a lot of that, it depends on the representative, intuitive representative in your area. I know for some reasons it's more difficult, Pittsburgh is difficult, but I understand that's not the same in other states and all depends on the relationship that you have. Right now, as of right now, intuitive has not shown too much interest in training plastic surgeons. Now, I don't think they had interest on investing time and money, you know, to get an IDE. I know that Jesse did the whole pretty much case collection and protocol for an IDE for the latissimus and there was no interest in pursuing that further out of 510K. But I think things are gonna change in the next few years for several reasons. First of all, there will be other, you know, companies coming with robots. There are several in the process of collecting data right now. And as I showed in my presentation, and so there will be competition, right? And the competition is good for what we do. And they do also might want to get more educations for the SP model, which is a single port, and maybe plastic surgery might be appealing to them at that point. But it's not that easy. And that's one thing that the task force is actually trying to active work on it. Yeah, and just chime in there. So I did the combined general surgery placerity route. So I had three years of general surgery, three years of placerity. I did a ton of laparoscopy. And I'll tell you, I was disappointed, full disclosure, when we went back to the integrated route, because I felt like we left, you know, kind of like the cradle of where we start. So I'm all for having more independent programs or even having more general surgery training within our residency program. Because I feel like with this new innovation coming in robotics, we're going to miss out on that training because it's all robot all the time in general surgery. And our placerity trainings don't get it. And we're not going to get it because we're in this integrated, less and less general surgery. So this is recorded, bring that to your task force. And you know. Yeah. So one thing- Let me just, before- Can I just make one comment? I'll be done in a second. One thing that we have to discuss at what kind of certification we want, right? We don't want to learn how to do gall bladders and resect a column or things like that. Is that a way that we can find a different path for certification for plastic surgeons? Number one. Number two is we have to figure it out a way to integrate robotic training into plastic surgery training. It's, you're right, plastic surgeons residents do less and less general surgery. I'm very sure that with, if we discuss with general surgery program director and plastic surgery program director, bring this to the IRC, maybe over time we'll be able to get a different pathway for certification for plastic surgeons. So I think, you know, this is a very important topic and it does segue into, you know, Dr. Graham-Schwartz. What I was going to ask him is that, you know, essentially the training is one issue and getting buy-in from your hospital is another. When you talk about the training or the credentialing or the privileging, you have to consider, you know, the level of expertise. So we're talking about, you know, these are residents or senior level residents, chief level residents, microsurgery fellows, junior faculty. I'm a mid-level faculty who learned this just a year ago. And my path to this was, I got my institution to credential Jesse Selber as a plastic surgeon at Northwell for three days. That was torture, but we did it. He came down and that's how my institution allowed me to do it. And he was with us for three days and he was literally a surgeon with us doing those cases. So my question to you, Graham, is that, you know, what do you, you know, to the viewers out there of varying levels of expertise, you know, what are the various pathways that they can adopt robotic surgery into clinical practice, you know, from a just practical standpoint in terms of credentials or privileges. And then the other aspect of this is, you know, you're now taking an operation that we do reliably at most institutions. You know, we've gotten down, we were, you know, we've focused, we got down, you know, to a very quick operation, quick length of stay that you are, with the learning curve, you're gonna increase that, the operative time. And in a lot of places, robotic access is difficult. You know, when you have well-established operations like robotic prostatectomy, right? Or robotic, you know, general surgeries even further along. So how do you then talk to your hospital administrators and convince you to get robot time? So those are the sort of the two part question. I would love to hear your thoughts on that. So, well, I mean, I echo a lot of what, you know, a lot of what Dr. Morera said, you know, we're, you know, I'm at the Cleveland Clinic, you know, and certainly involved, you know, heavily in resident and microsurgery fellow training. And, you know, I think that we're in a bit of a privileged spot in that we, you know, sort of the, my institution values kind of innovation, pushing, you know, kind of pushing the envelope forward. So I think that perhaps there's more of a permissive, you know, attitude about these types of things. So basically, you know, our paradigm has been that, you know, we have a very supportive kind of leadership, you know, in our institute and department. And so they kind of lead the way. And we also have a lot of collaborative partners in other disciplines who are willing to fortunately teach us. And I think that, you know, as we, you know, we are by nature a collaborative specialty, you know, and we show our, you know, we show our collaboration by helping other specialties with their challenges, help train, you know, other residents. And so they're, you know, we're at least lucky to receive some reciprocity, you know, in that regard. So I can't say that that's an easy model, you know, for all, you know, for all institutions and all plastic surgeons, but that's how we do. And I think that, you know, it's something that we can try. I think setting up discrete pathways is important though. And I think part of the role, you know, I think part of the charge of the Robotic Surgery Task Force, you know, that Justin and Andrea and Jesse and the whole team here is trying to do is to try to push this, you know, forward so it's more acceptable and we can bring it to sort of our own respective, you know, institutions and leadership to help, you know, train our, you know, train our future. So I'm sure everybody else has a little bit to say on this topic too. Yeah, no, I think it's definitely an interesting one and one that we will come back to. I do want to get some perspectives from our fifth panelist, Dr. David Kurlander. You know, he's going to be talking about program development, but one aspect that I'd like to ask you is, you know, we haven't considered the patient and, you know, I'd like to know what do you tell your patients as it pertains to use of robotic surgery? What are the benefits? You know, where are the studies? What are the outcomes that you're measuring? And it sounds great, but if you have a patient who wants the data, what data are you giving them? What long-term outcome data? What patient reported outcomes are there on this or lack thereof? So I'd like to see, you know, in your preoperative counseling, you know, what are you talking to the patients about? Yeah, thanks Dr. Tanna for the question and for having me. I'm in my second year of practice at Rush. And so I'm clearly the most junior member on this panel. I was fortunate enough to, I did integrated plastic surgery residency, so no specific robotic or laparoscopic training, but I was lucky to train with Dr. Selber in fellowship where I took an interest and became competent in the robot. And then I was lucky to land at Rush where the hospital institution and my division has been very supportive of robotics in plastic surgery. And so, you know, what it comes down to for me is who are the patients that are going to be at home run? So I'm early in practice. I am not doing, you know, three deeps a week. I'm building a practice. And so if I'm going to do it, I need to convince the hospital. I need to convince the OR. I need to convince myself. And I need to make sure the patient is the right patient to do the operation. And so for me, it's mostly robotic deeps. Occasionally it's a robotic rectus for APR after a robotic APR. And who are those patients? Occasionally it's a patient who asks for it. And so that may be directly or indirectly someone who, you know, the first patient that I did was a CrossFit athlete, had a lot of extra skin, lost a lot of weight, was concerned about abdominal morbidity, right? And so this patient was begging for a tiny incision and in a fast recovery and quick return to their CrossFit activity. And so in that patient, it's a high yield who had a, you know, an appropriate CT scan. That's someone I feel very comfortable counseling that you will have a significant benefit. There's not decades of data, but there's anecdotal data and there's a growing body of literature that it's safe and that it's effective. Who are the other patients? It's someone that I consider to be high risk for hernia or bulge. And so usually that's larger patients. We get CT scans before all our deep flaps and it's patients who have a large perforator that's high and has a short intramuscular course, which will then give us a short fascial incision length and someone who I can keep that fascial incision above the arcuate line. And so actually Dr. Selber and I looked at this when I was a fellow and about 70% of patients have one side or the other that's amenable to that sort of anatomy on their skin. And so in two years, I've done a handful of these. It's probably about 15% of the deeps that I do are robotic. So it's not everyone. And there are a lot of challenges and barriers to growing that number from 15% to a higher percentage. But I feel very comfortable telling patients that this is a safe surgery. I do the robot. I have a general surgeon on standby. If there's any issues with adhesions or difficulty with the dissection, but it's something that I think can benefit them, then we should go ahead with it. And I've told the handful of patients that I've done, you're one of the first people to have this surgery and at Rush, you're one of the first people in the Midwest. And I haven't had any pushback from many of these patients. Yeah, David, I'm smiling here as you're speaking because it really, for the viewer out there, it doesn't matter how many years you're into practice. It really matters where you are on this learning curve. So I'm about 15 months and literally everything you said resonates because I'm literally going through what you're going through. I would say first to anyone listening is listen to your patients, listen to your patients and you will find the one that wants it and will motivate you. And that's what actually, that's truly what happened in this situation for me was because I had a patient who, in New York, our patients are very well-informed who said, I want a robotic deep flap. Googled Jesse Selber, said, I want this guy and literally pushed me and said, and I was like, no, this guy's crazy. You don't want him and pushed me. And literally when Selber came, she treated him like a celebrity, was getting an autograph and everything. But the reality is if you listen to your patients, they're gonna guide you to that. And then I think you're right. Be very conservative in your selection. Those medial wraparound perforators, that's the best one to start off with, that it just, it goes intramuscular right away. And then you start slowly evolving from there. And we started doing delayed first, then we now started doing immediate. We started doing unilaterals, now we're doing bilaterals. And so it's just, you start to evolve. And what's great is that I think we'll all exchange ideas in this, but I think this is an exciting field and it's one that we're all kind of going through this together. And we were lucky to have pioneers like Dr. Levin and Dr. Salber kind of to guide us forward. I think we can, with the last few minutes, let's open it up to the entire group. Justin, is there anything that you have left to ask anyone or we can kind of open it up? So we'll take another five or six minutes here. And what I would say is tomorrow when you go to work, to each panelist and keep it brief, how would you use the robot tomorrow most effectively to improve your practice? Like just one or two sentences, how would you improve your practice tomorrow if you had unlimited usage of the robot for current state? Jesse. All right, so tomorrow I'm doing an immediate reconstruction autologous on a patient who's getting a mastectomy and an axillary lymph node dissection, right? So this person's gonna get reverse lymphatic mapping. They're gonna have lymphatics identified that can be connected to a lateral thoracic vein. Now, if I had my way, this would be done with a robotic nipple sparing mastectomy through a three centimeter lateral incision. This is something that we're starting trial on next month. A robotic deep then passed up with an anastomosis to the thoracic dorsals robotically and a robotic lymphatic repair. That's a total robotic breast reconstruction, very minimal fascial incision, very minimal breast incision, lymphatic reconstruction. First, do no harm and solve as many problems as we can. Great answer, David. Yeah, I'm simple, right? I wanna get the operation done and done safely. And so for me, the benefit of the robot really is the benefit of CAD CAM, right? So there are some people that can make a tiny fascial incision, not use the robot, dissect it all the way down through a two centimeter fascial incision. I'm not that person. You know, Ron, you can hand cut a fibula in about 10 minutes. I need the CAD CAM, right? And so for me, it's just using the robot to make a small fascial incision, get the patient out of the hospital and recovered with as little pain as possible. So it's simply just a robotic leap. Graham. What I want, I'm not gonna get tomorrow. What I want is I want the ability to position the robot, choose the patients, use my AI to help me select the patients and to effectively bring the robot into where it needs to go, make the incision, do the subtask of doing my lymphatic venous bypass and then, you know, and then leave. I don't wanna necessarily have to do the lymphatic venous bypass, even though I love to do microsurgery and super microsurgery. I think I might be just as happy to press a button and have the robot do the microsurgery for me. Outstanding. Andrea, close it, close it. I know, now it's difficult because everybody said pretty much everything that I wanna say. Make something up. I'll make something up. You know, I would love to follow what Jesse said and add robotic resensation of the breast. I wanna dissect the intercostal nerve, do the lymph, do the robotic mastectomy, do the robotic tip and connect a nerve to the nipple if possible. And I wanna do it fast in a very efficient way with a team that actually is trained for robotic plastic surgery in a hospital that gives you support to do so. I think that would be ideal in an institution where I can train residents to learn how to do it. Outstanding. Neil, you go. How would you use it tomorrow? Yeah, no, I think Jesse and I, we talk about this all the time. Just for anybody who's listening out there, you know, and critics like I was, just think about this for a second. A woman with BRCA who's getting a robotic oophorectomy, there's no reason why she shouldn't get a robotic deep flap if she's getting autologous reconstruction. And then like Jesse said, a robotic nipple sparing mastectomy, pass it up from underneath. No, you know, just the very minimal incision in what I would say is risk reduction in a day. That's really what this is about. If I go to work tomorrow, I put something on that augments my hands to be better and more secure as I get older. I agree with Dr. Levin, what he said, because in my car at night in the rain, my car drives better than me and sees better than me. That technology augments me, makes me a better driver, makes my kids better drivers. End of sentence, full period, stop. Anyway, this has been one of the better panels that I've been on. I'm less fearful now about robotic surgery than when I started. So I want to thank all the panelists for shedding light on the evolving role of robotic surgery and plastic surgery. It's very clear that the future holds much promise as we navigate the integration of technology with patient care. Your expertise and experiences are instrumental in understanding and molding the path forward. To all our attendees and panelists, Dr. Selber, Dr. Perlander, Dr. Schwartz, Dr. Marrera, Dr. Levin, who's taking out the Ukrainian surgeons right now for dinner, pen pop course with them. Let's continue the conversation, work together towards meaningful advancements in this field. My co-partner here, Dr. Neal Tanna, thank you for pushing the envelope also, robotic surgery in New York City. But it's been a great panel and I think that's it. We did it.

robotic technology

plastic surgery

surgical precision

DaVinci robot

surgical robots market

Robotic Task Force

American Society of Plastic Surgeons

regulatory challenges

educational needs

FDA approval

artificial intelligence

surgical applications

policy changes