Smart hands: robotic systems as surgical collaborators in plastic and reconstructive surgery

Robotic systems, artificial intelligence (AI), and augmented reality (AR) are increasingly reshaping plastic and reconstructive surgery by enhancing precision, reproducibility, and surgical decision-making. While conventional robotic platforms such as the Da Vinci system have demonstrated clear benefits in minimally invasive surgery, their application in microsurgery has remained limited due to instrument size and insufficient submillimetric control. Recently developed microsurgical platforms, including the Symani® Surgical System (Medical Microinstruments, Pisa, Italy) and the MUSA® system (MicroSure B.V., Eindhoven, The Netherlands), address these limitations through motion scaling, tremor suppression, and compatibility with open-field reconstruction. Early clinical studies report successful lymphatic and microvascular anastomoses, improved ergonomics, and reduced surgeon fatigue, marking a significant step toward routine robot-assisted microsurgery. In parallel, advances in AI and machine learning enable data-driven surgical planning, perforator mapping, flap selection, complication prediction, and automated documentation. Large language models further support clinical workflows through structured documentation and patient communication, while AR and virtual reality enhance anatomical orientation, intraoperative navigation, and surgical training. Despite these advances, challenges remain, including heterogeneous data quality, algorithmic bias, limited interoperability, and evolving regulatory frameworks. Addressing these issues is essential to ensure safe and equitable implementation. Future developments are expected to converge into an integrated, AI-augmented surgical ecosystem combining preoperative planning, robotic execution, and outcome-based learning. Rather than replacing surgical expertise, these technologies aim to augment human skill and support a more personalized and efficient reconstructive practice.