Endoscopic thoracic sympathectomy, while effective for palmar hyperhidrosis, results in devastating compensatory sweating and autonomic dysfunction affecting >80% of patients. We present our institutional evolution of robotic-assisted sympathetic trunk reconstruction (STR) for post-sympathectomy complications. Our prospective series of 23 patients underwent robotic STR with free nerve grafting (mean follow-up: 2 years). Six-month outcomes demonstrated significant improvement: Chest severity 9.4 ± 0.9 to 6.0 ± 2.4 (p < 0.001), back severity 9.3 ± 0.8 to 6.1 ± 2.6 (p < 0.001), with sustained gains at 2 years. To minimize donor site morbidity, we progressively transitioned to free intercostal nerve autografts, followed by vascularized intercostal nerve (vICN) grafting beginning January 2025. Vascularized grafts maintained immediate perfusion, enabling continuous Schwann cell proliferation and accelerated recovery. A propensity score-matched analysis of vICN versus free intercostal grafts achieved 100% technical success with no vascular complications. Six-month vICN recipients demonstrated continuous improvement without temporary worsening observed in controls. Recently, single-port robotic systems substantially reduced postoperative chest wall morbidity. These innovations demonstrate that precisely executed microsurgical technique, enabled by robotic precision and interdisciplinary expertise, offers viable treatment for carefully selected patients with intolerable post-sympathectomy complications.