The Pinedas were worried about their baby’s future. Often, if left untreated, cleft lip and palate can lead to speech and socioemotional developmental delays. Some babies also face feeding issues.

However, even before the parents reached their home, Victor Chien, MD, a pediatric plastic surgeon and director of Pediatric Cleft and Craniofacial Surgery at Cedars-Sinai Guerin Children's, called the Pinedas to reassure them and offer a novel solution: robot-assisted surgery.

“We left the ultrasound feeling really sad with the news,” Marisol Pineda said. “But Dr. Chien reassured us that everything was going to be okay. He explained that although Luka has a cleft lip and palate, he would be able to fix it.”

July marks National Cleft and Craniofacial Awareness and Prevention Month. A cleft lip typically occurs when the tissues that make up the upper lip don’t join properly before birth. Children born with a cleft lip can also have a cleft palate—a condition in which the roof of the mouth doesn’t fuse properly. About 1 in every 1,031 babies in the United States is born with cleft lip with or without cleft palate, according to the Centers for Disease Control and Prevention.

Luka was born prematurely at 33 weeks of gestation and was immediately admitted to the Neonatal Intensive Care Unit (NICU) at Cedars-Sinai Guerin Children’s. In addition to being a preterm baby, Luka experienced breathing difficulties due to his cleft lip, which made it hard for him to close his mouth. He also gained weight more slowly because he struggled to latch onto the bottle, so he required a temporary feeding tube.

At first, Luka’s parents were apprehensive about a robot assisting with the surgery. But Chien reassured them by explaining the procedure. However, he recommended waiting until Luka weighed at least around 10 pounds or was 3 months old.

Robot-assisted cleft lip repairs are still under Food and Drug Administration review and have been used only in a handful of cases. Surgeons control the robot remotely, facing a screen away from the patient, performing the surgery using chopstick-like instruments, which allows for finer movements in small spaces like an infant’s mouth.

“The robot-assisted approach takes about the same time as the traditional approach, but it offers surgeons enhanced precision, especially when carefully separating delicate tissue and suturing. We’re using the robot for key fine sutures in three critical layers of the lip repair and now superfine dissection,” Chien said. “The main thing we are trying to reduce with all the finer techniques a robot offers is the amount of trauma and scarring on the smallest, delicate tissues.”

Furthermore, robotic assistance reduces awkward operating positions for surgeons working on the smallest patients. Chien noted that the robot’s precision eliminates hand tremors, making the procedure “gentler on the tissues.”

The family put their trust in Chien—and the results amazed them.

Following his robotic cleft lip repair, Luka was smiling, thriving and finally able to gain weight as feeding became easier.

“Physically, the surgery made a big difference. My son’s lips looked really good. The scarring was barely noticeable,” Pineda said. “He’s such a happy baby. He smiles a lot.”

Earlier this year, Luka underwent his second surgery to repair his cleft palate, an opening in the roof of the mouth that made eating solid foods and swallowing difficult. While the robot was not used for that procedure, the operation was successful, marking another important milestone in his care.

Today, at 18 months, Luka is active and playful just like any other toddler and is meeting developmental milestones. Pineda said she is relieved his early feeding struggles are behind him.

“The thing about a cleft lip and palate is there are so many emotions and worries that come with it, but we’re grateful for the advancements in technology and the care Luka received,” Pineda said. “He loves to eat; he’s such a happy eater. You would never know everything he’s been through.”

Chien is optimistic about what robotic surgery can offer and is eager to train future surgeons to adopt the technology.

“This technology could transform the way we perform delicate pediatric procedures,” he said. “It’s a new frontier for plastic surgery.”

Read more from Cedars-Sinai Stories and Insights: Cleft Lip and Cleft Palate FAQ

Microsurgery is a highly specialized technique used to connect tiny blood vessels. With the remote-controlled Symani Surgical System, surgeons sit in a unique chair and use hand controllers, which reduce natural hand tremors, to perform the delicate technique while a 3D screen magnifies the operating area.

Chien, who performed the surgery, told KTLA 5 “Rich on Tech” reporter Rich DeMuro the system allows for remarkable precision when connecting vessels thinner than a human hair.

“This robot and the three-dimensional aspect of the visualization allows us to add efficiency and precision to these very difficult cases,” Chien said.

Cetrulo, director of the Division of Plastic Surgery and the General William and Willa Dean Lyon Family Chair in Reconstructive and Plastic Surgery in honor of Randolph Sherman, MD, added, “What we’re watching on the screen, it could look normal to us, but in reality, it’s absolutely tiny.”

Cetrulo told DeMuro the surgery performed at Cedars-Sinai was a “100 percent success” and it could “open up a whole-new avenue of treatments for patients for diseases we never even considered treating.”

The surgeons noted robot-assisted microsurgery could one day be used for brain, abdomen and chest surgeries.

“These tools allow us to use our mastery in a level of precision and a level of dedication that was not previously possible,” Chien told DeMuro. 

Click here to watch the complete segment on KTLA 5.

"He casually asked me, ‘Deven, what do you think about a robot doing your surgery?’” Phillips said. “I asked if he was going to be in the room. He said, ‘Of course, I will be there.’”

That was reassuring enough for her to go ahead with the robot-assisted surgery, making Phillips, an elementary school teacher in Rancho Cucamonga, the first patient at Cedars-Sinai to undergo the robot-assisted microsurgery for lymphovenous bypass. It’s a minimally invasive procedure involving rerouting blocked lymphatic vessels using sutures thinner than human hair to alleviate fluid buildup and improve drainage for people with lymphedema.

Lymphedema causes painful swelling due to lymphatic fluid buildup, and can result from cancer treatments, such as chemotherapy, radiation and lymph node removal. Phillips developed the condition in her arms after undergoing extensive breast cancer treatments following her 2017 diagnosis.

The surgical team was led by Philip Brazio, MD, a plastic surgeon in the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai and program director of the Complex Reconstruction and Microsurgery Fellowship program, who utilized the Symani Surgical System. The robotic platform, Brazio said, significantly improves the precision and control necessary to carry out the delicate and complex surgery.

“It translates my movements into smaller movements,” he said. “The robot helps filter out tremors that everyone has to some degree. The key to operating on such small vessels is working with that precision.”

Handling the robot, according to Brazio, is akin to playing a virtual reality video game. In the operating room, the surgeon wears 3D goggles and manipulates chopstick-like hand instruments while viewing a magnified screen that highlights the minuscule lymphatic vessels. The robot executes the surgeon’s precise maneuvers on the patient, potentially minimizing scarring and vessel damage.

“Ergonomically, it’s a huge advantage,” Brazio said. “We’re able to sit up straight instead of leaning over sideways or operating at awkward angles, which reduces fatigue and increases surgical accuracy.”

Cedars-Sinai is the first program in the western United States to offer microsurgical robotic capabilities. The platform can be utilized for other complex procedures, such as breast reconstruction following cancer treatment; lower extremity microsurgical reconstruction, which involves microsurgery to repair tissues in the lower limbs following injury, disease or congenital defects; and head and neck cancer reconstruction surgery to remove tumors from hard-to-reach areas.

Though Phillips had undergone a previous lymphatic surgery and relied on traditional treatments like compression garments and physical therapy, she had been living with the debilitating effects of lymphedema for years. But after undergoing the robot-assisted lymphatic surgery, she was able to bounce back to her routine within days.

Phillips’ recovery aligns with what Curtis L. Cetrulo Jr., MD, vice chair of Research in the Jim and Eleanor Randall Department of Surgery and director of the Division of Plastic Surgery at Cedars-Sinai, envisioned.  

“Due to the greater levels of precision the robotic platform lends, it enables us to treat more lymphatic pathways, potentially improving lymphatic drainage, providing symptom relief,” Cetrulo said. “Through the use of the robot-assisted technology, we’re building a team of highly skilled surgeons, and our Complex Reconstruction and Microsurgery Fellowship program is one of the first in the nation to train fellows in robotic-assisted microsurgical technique.”

Cetrulo added that Cedars-Sinai—being one of the first institutions in the country to adopt innovative robot-assisted procedures—is paving the way to potentially broaden access to life-changing treatments that significantly improve quality of life for patients like Phillips.

“I’m looking forward to getting back into the gym, lifting weights and getting back to where I want to be,” she said. “Most importantly, I would love to be able to wear my wedding ring again.”

Read more from the Cedars-Sinai Blog: Pioneering Advances in Surgery

Cedars-Sinai has successfully performed the first robot-assisted microsurgical head and neck cancer reconstructive surgery in the United States after the robot device received Food and Drug Administration approval for the procedure, marking a significant milestone in surgical advancements.

This procedure underscores Cedars-Sinai's commitment to staying at the forefront of medical innovation and adopting leading-edge surgical techniques that positively enhance patient care and improve outcomes.

The surgery was performed by Victor Chien, MD, who utilized the Symani Surgical System. Chien said the robot enabled him and his team to perform a complex microsurgical procedure with a higher level of precision and control than conventional methods to operate on micro blood vessels thinner than a human hair.

“The surgery demonstrates the microsurgical platform’s remarkable ability in lending greater precision and care when handling tissue in small and diseased vessels,” said Chien, a plastic surgeon in the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai. “By removing the limitations that come with natural tremor in a human hand, the robot helped us execute this procedure in an efficient manner.”

Microsurgery is a highly specialized technique that involves connecting tiny vessels to restore blood flow or redirect fluid during surgical procedures. The microsurgery robot is designed to augment a microsurgeon’s capability to carry out surgery at the micro level by adding precision and control for extremely delicate procedures where surgical options may otherwise be limited. Additionally, Chien noted that robotic assistance greatly enhances 3D visualization and dexterity, enabling skilled microsurgeons to navigate complex areas more easily.

“Enlisting the technology potentially minimizes scarring and tissue damage, and I expect the added precision will ultimately increase operative efficiency,” Chien said.

Besides head and neck reconstruction surgery, the robot can be utilized for other complex procedures, such as breast reconstruction following cancer treatment; lower extremity microsurgical reconstruction, which involves microsurgery to repair tissues in the lower limbs following injury, disease or congenital defects; and lymphovenous bypass procedure for lymphedema, a procedure involving rerouting blocked lymphatic vessels to reduce fluid buildup caused by complications from radiation therapy.

“We are the first program in the Western U.S. to have microsurgical robotic capabilities and to perform a wide variety of successful cases using the device,” said Curtis L. Cetrulo Jr., MD, vice chair of Research in the Jim and Eleanor Randall Department of Surgery and director of the Division of Plastic Surgery at Cedars-Sinai. “We are building a robust corps of highly skilled surgeons and fellows trained in robot-assisted microsurgical technique, and we are excited to provide these innovative treatment options to our patients.”

Read more from the Cedars-Sinai Blog: Pioneering Advances in Surgery

Cedars-Sinai, part of a national multicenter consortium, will be responsible for developing protocols for the procurement and preservation of donor tissue as well as the eye transplant surgeries themselves. The Cedars-Sinai effort is being led by Curtis L. Cetrulo Jr., MD, vice chair of Research in the Jim and Eleanor Randall Department of Surgery and director of the Division of Plastic Surgery at Cedars-Sinai.

“Vision loss affects over 7 million Americans and this award represents an opportunity to really move the needle in our treatment of blindness. With this funding, I’m confident we can make progress toward eye transplantation,” Cetrulo said. “As the only clinically active vascularized composite allotransplantation program approved for face and eye transplantation on the West Coast, we are in a unique position to design the protocols that will allow for successful optic nerve connection and regeneration. We will also be addressing preservation of the donor eye tissue in transit to safeguard the optic nerve and retina, which are very sensitive to periods of decreased blood flow.”

Cedars-Sinai joins several partners, including the University of Colorado Anschutz Medical Campus, the effort’s primary award recipient. The other partners are Johns Hopkins University, University of Wisconsin, Indiana University, University of Southern California, the National Eye Institute and the Foundation for Fighting Blindness. The ARPA-H funding for the project totals up to $46 million, with up to $6 million dedicated to Cedars-Sinai’s clinical surgical efforts.

ARPA-H is a federal agency established to advance high-potential, high-impact biomedical and health research that cannot be readily accomplished through traditional research or commercial activity. 

In its clinical transplantation practice, Cedars-Sinai will employ the robotic Symani Surgical System, which was recently acquired by the hospital. Currently, Cedars-Sinai is the only institution on the West Coast utilizing this new and highly specialized robotic microsurgery technology, which scales down the surgeon’s movements significantly for extreme precision.

“This is just another example of how the Department of Surgery at Cedars-Sinai strives to be at the forefront of the most innovative and life-changing procedures,” said Cristina Ferrone, MD, chair of the Department of Surgery at Cedars-Sinai and the Linda and Jim Lippman Chair in Surgical Oncology. “The work our team is doing on this project has the potential to transform clinical practice and impact the lives of millions of people around the globe.”

Cedars-Sinai is a leader in treating eye disease with novel approaches. Previously, Clive Svendsen, PhD, professor of Biomedical Sciences and Medicine and executive director of the Cedars-Sinai Board of Governors Regenerative Medicine Institute, received a $10.5 million grant from the California Institute for Regenerative Medicine (CIRM) to launch a clinical trial testing treatments for retinitis pigmentosa, an inherited eye disease with no known cure.

Read more from the Cedars-Sinai Blog: Pioneering Advances in Surgery

Cetrulo is the second physician to fill the chair, which was initially held by the late Randolph Sherman, MD, and was founded by the Lyon family to advance training and research into new technologies to treat patients with complicated health conditions.

“It is a distinct honor to continue the work of Dr. Sherman, and I am grateful to the Lyon family for their generous support of our research at Cedars-Sinai,” said Cetrulo, also the director of Vascularized Composite Allotransplantation Program Development.  

Cetrulo, who joined Cedars-Sinai in late 2023, is an expert in complex adult and pediatric reconstructive microsurgery, hand surgery, breast reconstruction and burn reconstruction. Prior to joining Cedars-Sinai, he was an associate professor of Surgery at Harvard Medical School. He also served as Massachusetts General Hospital’s director of the Reconstructive Transplantation Service and director of the Vascularized Composite Allotransplantation Laboratory at the Center for Transplantation Sciences.

In addition to his clinical care, Cetrulo is known for his pioneering research. Cetrulo’s research has been published in more than 150 peer-reviewed medical journals. He has made significant research contributions to xenotransplantation, the process of transplanting tissues or organs between different species. This includes the first-in-human clinical trial at Massachusetts General, during which genetically modified laboratory pig skin was used to heal burn patients’ wounds. Cetrulo received an award from the American Burn Association for this innovative work. His work has resulted in multiple patents related to transplantation technology.

“Dr. Cetrulo’s leadership and expertise are tremendous assets to our patients and surgical teams,” said Cristina Ferrone, MD, chair of the Department of Surgery. “He is a world-renowned innovator and extremely deserving of this recognition. His impactful research will continue to drive innovation in medicine.”

After earning his bachelor’s degree at Stanford University, Cetrulo earned his medical degree from Tufts University School of Medicine in Boston. He completed a general surgery residency at Lahey Clinic Medical Center, followed by a plastic surgery residency at Long Island Plastic Surgical Group/Nassau County Medical Center. He also completed fellowships at New York University’s Institute of Reconstructive Plastic Surgery, Craniofacial and Microsurgical Tissue Engineering Research as well as The Buncke Clinic in San Francisco in hand and microsurgery.

Read more from Cedars-Sinai Catalyst: Donor Spotlight—General William and Willa Dean Lyon