The Application of Augmented Reality Technology in Free Flap Reconstruction: A Systematic Review

Augmented reality (AR) is an emerging technology in microsurgery for free flap reconstruction. AR allows surgeons to superimpose preoperative CT images onto the patient, providing real-time insight into the underlying anatomy and aiding in the decision-making process; however, there is limited empirical evidence supporting the effectiveness of this modality. We conducted a systematic review to investigate whether the use of AR devices in free flap reconstruction correlates with improved outcomes.

A comprehensive search of PubMed, Embase, and Scopus was performed on February 19, 2025. Our search included retrospective and prospective articles that demonstrated the use of AR technology intraoperatively and reported surgical outcomes in any type of free flap reconstruction. The initial search yielded 158 articles, with 8 ultimately included in the study. Articles were reviewed for technical accuracy, surgeon ease of use, operative time, complications, and operative costs.

AR can guide surgeons, particularly those with less experience. As surgeons gain a better understanding of perforator locations, they operate with increased confidence and efficiency. AR outperformed Doppler ultrasound in perforator identification, demonstrating higher accuracy during flap planning and dissection. The time required to harvest flaps was significantly shorter when AR was used compared to traditional flap dissection techniques. Compared to computer-aided design and computer-aided manufacturing (CAD/CAM) navigation systems, AR surgical guidance exhibited greater accuracy and required significantly less time for flap design. AR devices surpassed cutting guides in various aspects, including cost savings, reduced preparation time, increased flexibility in surgical plan modification, intraoperative tissue drift, and a more favorable effect on hand-eye coordination. No conclusive postoperative complications were reported.

The majority of the literature about AR in free flap surgery comes from small clinical studies. Widescale, multi-center studies are necessary to determine the true clinical impact of AR technology in microsurgery.