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

Authors: Speck NE, Rodriguez M, Lunger A, Pfister P, Schaefer DJ, Burger M, Shuck JW, Largo RD, Ismail T, Muller L.

Affiliation: Dept of Plastic Surgery & Head and Neck Surgery, University Hospital Basel, Basel, Switzerland; University of Texas MD Anderson Cancer Center, Houston, Texas

Journal: Plastic and Reconstructive Surgery Global Open, February 2026.

PMID: 41635721.

Key takeaways

• This is a clever pedicle-routing refinement for TORS reconstruction.

• The main innovation is a 1- to 2-cm nerve- and vessel-sparing mini-pharyngotomy that allows “inside-out” pedicle transfer while avoiding mandibulotomy and traditional lateral pharyngotomy.

• For practicing plastic surgeons, this is best viewed as a niche technique for experienced TORS/free-flap teams, not a standard approach to adopt broadly tomorrow.

Background

TORS is now a mature ablative platform for selected head and neck tumors, but reconstruction remains the bottleneck when defects are too large for secondary healing or local options. Reviews of post-TORS reconstruction note that larger, irradiated, or more complex defects increasingly require vascularized tissue, yet data on robotic-assisted inset remain limited.

Objective

To describe a minimally invasive method for transoral robotic free-flap inset and pedicle positioning in oro- and hypopharyngeal defects using a small transcervical mini-pharyngotomy designed to spare major nerves and vessels.

Methods

• Design: Technical case series from 2017 to 2024; no comparator group.

• Patients: 4 patients, all ASA 3, ages 44 to 67 years. Indications included osteoradionecrosis, chronic osteomyelitis after prior cancer treatment, synovial sarcoma, and tonsillar SCC.

• Flaps: All 4 reconstructions used a radial forearm free flap; pedicle lengths were 6, 6, 10, and 12 cm.

• Technique:

  • Posterior/lateral pharyngeal defects: lateral mini-pharyngotomy between the caudolateral resection edge and the neck.

  • Anterior oropharyngeal defects: submandibular approach with hyoid retraction and a vallecular-level mini-pharyngotomy.

  • Incision size was 1 to 2 cm, oriented along constrictor fibers, and just large enough to avoid pedicle compression.

  • The pedicle was passed “inside-out” through a Penrose drain filled with irrigation fluid.

• Inset/anastomosis: Manual suturing where accessible, robotic suturing for deep or poorly exposed portions, arterial anastomosis to the superior thyroid artery, venous anastomosis to the internal jugular system.

• Perioperative pathway: Oral intake began after leak testing at about 10 days in nonirradiated patients and 3 weeks in irradiated patients.

Results

• Median defect size was 23.4 ± 9.7 cm²; recorded defects ranged from 12.25 to 30 cm².

• Operative times were 420, 452, 463, and 487 minutes; the authors report a mean of 455.5 ± 27.8 minutes.

• No flap loss, leak, fistula, or infection occurred. All patients were decannulated by discharge. Follow-up ranged from 9 to 70 months.

• Two patients required reoperation:

  • 1 postoperative hematoma managed with arterial clipping, flap salvaged.

  • 1 delayed tracheal bleed on postoperative day 16 requiring neck exploration and sternotomy; no arteria lusoria was found.

• Put plainly, the series achieved its technical end point, but half the cohort still returned to the OR.

Conclusion

The authors conclude that robotic-assisted inset using a mini-pharyngotomy is a safe, effective, minimally invasive alternative to conventional access for selected complex oro- and hypopharyngeal reconstructions. That conclusion is reasonable as a technical feasibility statement, but it is stronger than the data support if interpreted as evidence of superiority.

Strengths

• Clear technical description with practical anatomy-based modification for pedicle transfer.

• Challenging real-world cases, including previously irradiated and infected fields.

• Reasonable follow-up window for a technical note, up to 70 months in one patient.

Limitations

• n = 4, single-center, highly selected patients; this is strictly hypothesis-generating.

• No control group against standard transcervical pedicle routing, lateral pharyngotomy, or nonrobotic inset.

• All flaps were radial forearm flaps, so generalizability to bulkier ALT or perforator flaps is uncertain.