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Use of Augmented Reality in Reconstructive Microsurgery: A Systematic

Review and Development of the Augmented Reality Microsurgery Score

Article  in  Journal of Reconstructive Microsurgery · December 2019

DOI: 10.1055/s-0039-3401832

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Original Article

Use of Augmented Reality in Reconstructive

Microsurgery: A Systematic Review and
Development of the Augmented Reality
Microsurgery Score
Yasser Al Omran, BSc (Hons), MBBS, MRCS, MRCP, MSc (Dist)1 Ali Abdall-Razak, BSc (Hons)2
Catrin Sohrabi, BSc (Hons), PhD3 Tiffanie-Marie Borg, BSc (Hons)3 Hayat Nadama, BSc (Hons)4
Nader Ghassemi, MBChB5 Khine Oo6 Ali M. Ghanem, MD, MPhil, MSc, PhD, FRCS (Plast)3

1 Department of Plastic Surgery, Birmingham Women’s and Children’s
Hospital NHS Foundation Trust, Birmingham Children’s Hospital
Steelhouse Lane, Birmingham, United Kingdom
2 Imperial College School of Medicine, London, United Kingdom
3 Academic Plastic Surgery Group, Barts and The London School of
Address for correspondence Yasser Al Omran, BSc (Hons), MBBS,
MRCS, MRCP, MSc (Dist), Department of Plastic Surgery, Birmingham
Women’s and Children’s Hospital NHS Foundation Trust, Birmingham
Children’s Hospital Steelhouse Lane Birmingham B4 6NH,
Birmingham B15 2TG, United Kingdom

Downloaded by: Queen Mary, University of London. Copyrighted material.

Medicine and Dentistry, London, United Kingdom (e-mail: yasseralomran@yahoo.com).
4 University of Nottingham School of Medicine, Nottingham,
United Kingdom
5 Department of Surgery, University Hospital North Midlands NHS
Foundation Trust, Stoke-on-Trent, Staffordshire, United Kingdom
6 Keele University School of Medicine, Keele, Staffordshire, United Kingdom

J Reconstr Microsurg

Abstract Introduction Augmented reality (AR) uses a set of technologies that overlays digital
information into the real world, giving the user access to both digital and real-world
environments in congruity. AR may be specifically fruitful in reconstructive microsur-
gery due to the dynamic nature of surgeries performed and the small structures
encountered in these operations. The aim of this study was to conduct a high-quality
preferred reporting items for systematic reviews and meta-analyses (PRISMA) and
assessment of multiple systematic reviews 2 (AMSTAR 2) compliant systematic review
evaluating the use of AR in reconstructive microsurgery.
Methods A systematic literature search of Medline, EMBASE, and Web of Science
databases was performed using appropriate search terms to identify all applications of
AR in reconstructive microsurgery from inception to December 2018. Articles that did
not meet the objectives of the study were excluded. A qualitative synthesis was
performed of those articles that met the inclusion criteria.
Results A total of 686 articles were identified from title and abstract review. Five
studies met the inclusion criteria. Three of the studies used head-mounted displays,
one study used a display monitor, and one study demonstrated AR using spatial
navigation technology. The augmented reality microsurgery score was developed and
Keywords applied to each of the AR technologies and scores ranged from 8 to 12.
► augmented reality Conclusion Although higher quality studies reviewing the use of AR in reconstructive
► reconstruction microsurgery is needed, the feasibility of AR in reconstructive microsurgery has been
► technology demonstrated across different subspecialties of plastic surgery. AR applications, that

received Copyright © by Thieme Medical DOI https://doi.org/

July 19, 2019 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-3401832.
accepted after revision New York, NY 10001, USA. ISSN 0743-684X.
October 28, 2019 Tel: +1(212) 584-4662.
Use of AR in Reconstructive Microsurgery Al Omran et al.

are reproducible, user-friendly, and have clear benefit to the surgeon and patient, have
the greatest potential utility. Further research is required to validate its use and
overcome the barriers to its implementation.

Augmented reality (AR) is a rapidly growing field that uses

several technologies that superimposes digital information
(sounds, texts, and graphics) into the real world to enhance
the users natural vision.1 This is contrast to virtual reality
whereby the user is focused on a digital environment that
replaces the real-world environment (►Fig. 1). In surgery, AR
may provide the surgeon with access to a plurality of mediums,
including radiological, sonographic, photographic images,
GPS, and motion tracking to project computer-generated
content onto the physical landscape, which enable for better
contextual surgical planning and navigation.2 This is a feature

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that may be very beneficial in reconstructive microsurgery due
to the dynamic nature of operations in this field, and visuali-
zation of the delicate anatomy may be of significant utility.3,4
The use of AR has been explored in several other surgical
disciplines such as in general surgery,1 otolaryngology2 and
neurosurgery.5 Sayadi et al reviewed the use of AR and virtual
reality (VR) in plastic surgery, but there remained a paucity of
reconstructive microsurgery research articles in their review
and their literature search was limited to one database.6
Consequently, there has yet to be a systematic review that
has comprehensively evaluated the use of AR in reconstructive
surgery. With the increased use of AR in surgery year upon year
(►Fig. 2), a high-quality systematic review exploring the use of
AR and plastic surgery is therefore warranted to explore
current AR technologies and to guide future AR-related strate-
gies that can be used in reconstructive surgery.
The aims of this study are to (1) perform a comprehensive
systematic review of all human or cadaveric studies employ-
ing the use of AR in reconstructive microsurgery with a
Fig. 2 Number of articles published and indexed by Scopus per year
under the search term “augmented reality surgery.”
particular emphasis on clinical applications and educational
training; and (2) characterize and quantify the status and the
value of the identified AR applications within the field of
reconstructive microsurgery.
Methods
This systematic review was conducted in line with “preferred
reporting items for systematic reviews and meta-analyses”
(PRISMA),7 and “assessment of multiple systematic reviews
2” (AMSTAR 2).8 This systematic review was performed in
line with the recommendations noted in the Cochrane

Fig. 1 Difference between virtual reality and augmented reality. (A) VR: the digital environment replaces the real-world environment and
therefore, the user is focused completely on the virtual world. (B) AR: overlays the digital environment into the real-world environment, enabling
the user to experience both the virtual and real-world environment. AR, augmented reality; VR, virtual reality.

Journal of Reconstructive Microsurgery

 Use of AR in Reconstructive Microsurgery
Handbook for Systematic Reviews,9 and was without tempo-
ral limits. The protocol had been generated a priori and was
registered with the unique UIN code: CRD42019137655 on
PROSPERO (https://www.crd.york.ac.uk/PROSPERO).
Medline, EMBASE, and Web of Science databases were
explored from inception until December 2018. Multiple
search strategies, “terms and combination of terms” were
created and managed using appropriate keywords in English
language and also composed of Boolean logical operators.
Used search terms included “microsurgery,” “reconstruc-
tion,” “plastic surgery,” “surgery,” “AR,” “mixed reality,”
“flap,” “free,” “transfer,” “smart glasses,” “head-up display,”
and “spatial.” The search was not restricted by language and
non-English continued beyond title and abstract screening
(since the abstract is normally provided in English). For full-
text screening, a native language speaker translated the text.
All studies involving human or cadaveric specimens that
primarily aimed to evaluate the use of an AR-related tech-
nology were included in this systematic review. Therefore,
level of evidence 1–5 of the Oxford Centre for Evidence-Based
Medicine were included. Duplicate studies, studies without
original research and animal studies were excluded.
Identified studies were subject to article selection. Article
selection occurred in two stages:(1) Titles and abstracts were
screened by two teams, composed of two researchers within
each team. Disagreements were settled through discussion.
When doubt remained about the eligibility, the study pro-
ceeded to the next stage. (2) Selected full-text articles were
downloaded and further assessed for inclusion by the two
teams. Differences were managed through discussion.
Upon finalization of included studies, data extraction
occurred. Data extraction occurred with two teams composed
of two researchers within each team. Disagreements were
settled through discussion. The teams extracted data indepen-
dently to mitigate the risk of errors. Disagreements were
discussed with the supervisor. Elements extracted included:
author names, countries and year of publication, study design
and level of evidence, conflicts of interest and funding, intention
(clinical or educational use), age of participants, AR device used
Table 1 Augmented reality microsurgery score
Category Criterial of clinical impact score
Quality of Oxford level of evidence (1–5)
recommendation
Correlation with Improved patient outcome reported by author
educational or
Improved educational outcome as reported by author
clinical impact
Clinical utility
Augmented Ease of implementation
reality features
Noninvasive
Potential to be cost-effective
Relative low barrier to implement
Transferable to other (sub) specialities
Al Omran et al.
in the study, number of patients, methodology employed, and
the clinical or educational outcomes reported by the author.
A risk of bias assessment was performed using the framework
generated by Murad et al for case series and case reports.10
In an attempt to synthesize the collected data and evalu-
ate the potential utility of the AR applications, an augmented
reality microsurgery (ARM) score was generated from the
extracted data. This was composed of three criteria: (1) the
quality of recommendation, (2) the correlation with clinical
or educational impact, and (3) the AR feature, with each
criterion providing a different weighting to provide a final
score out of 17 (►Table 1). A traffic light system was
generated for each of the included articles based on the final
scores to give a clinical utility of the potential AR model in
plastic surgery: a score of 1–8 was classified as “low” (red)
clinical utility, a score of 9–12 classified as “moderate”
(yellow), and a score of “13–17 classified as “high” (green).
Final scores were generated via consensus.
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Results
A total of 686 articles were identified, of which five were
included in this systematic review after consensus
(►Fig. 3).11–27 Articles were excluded if they did not meet
the inclusion criteria. In summary, the use of AR in reconstruc-
tive microsurgery was explored in five studies, consisting of 30
patients (►Table 2).14–16,24,25 AR was evaluated in a bilateral
lower limb lympho-venous anastomosis,20 seven anterior
lateral thigh flaps,21,28 one latissimus dorsi flap,25 one tensor
facia lata flap,25 15 deep inferior epigastric perforator (DIEP)
flaps,11,21 three medial sural artery perforator flaps, and three
posterior tibial artery perforator flaps.12 All of these studies
demonstrated a level of evidence of four with the exception of
the study from Nishimoto et al that showed a level of evidence
of five (►Table 2). Four of the included studies were published
in English with the exception of one study that was published
in French. All studies were published between 2016 and 2018.
The ARM score generated for the included studies ranged
from a score of 8 to 12, with three studies being scored as
Available score(s)
1–5
2
2
1–Useful but user can manage without it
2–Significantly eases intervention
3–Salvaged operation
1
1
1
1
1
Journal of Reconstructive Microsurgery
Use of AR in Reconstructive Microsurgery Al Omran et al.
Fig. 3 PRISMA diagram showing status of searched articles for review. PRISMA, preferred reporting items for systematic reviews and meta-
analyses.
“red,” one study being scored as “yellow,” and one study
being scored as “green” (►Table 3). All of the included studies
were considered at risk of methodological bias (►Table 4).
Discussion
Superimposing digital information into the real world to help
guide a surgical procedure may have a profound positive impact
on surgical training and patient outcomes.24 This application of
AR may result in easier dissections and a safer means to conduct
vital parts of the operation, a greater acquisition of surgical
understanding and skills and better outcomes for
patients.2,24,25 AR may therefore be particularly rewarding in
the field of reconstructive microsurgery due to the complexity
and intricate nature of this field, and a systematic review of its
use has yet to be performed. The aim of this systematic review
was to conduct a high-quality, PRISMA, and AMSTAR 2 compli-
ant systematic review that aimed to assess the use of AR in
plastic surgery.
Five studies were included in this systematic review
(►Table 2). Nishimoto et al demonstrated that infrared images
transmitted to see-through electronic glasses-enabled sur-
geons to more easily identify lymphatic vessels in a bilateral
Journal of Reconstructive Microsurgery
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lower limb lympho-venous surgery.20 This study employed
iodocyanine lymphography to help identifying lymphatic
vessels. In another study, Bigdeli et al demonstrated that AR
can be performed to superimpose indocyanine dye-based
angiography images onto the skin in assisting in intraoperative
flap design and postoperative free flap monitoring.21 The
Visionsense ICG-NIR-VA surgery system (Orangeburg, NY)
used by the authors showed blood flow characteristics of
tissue superimposed on the skin and displayed on a monitor.
Using this system, the authors report better intraoperative
decision-making and prompt detection of poorly perfused
tissue.21 The Visionsense system was used to salvage an area
of compromised flow in a deep inferior epigastric perforator
(DIEP) flap for immediate reconstruction after bilateral mas-
tectomy. Prior to free-flap transfer, the AR system detected an
area of malperfusion on the lateral tip of the right DIEP flap and
this was resected prior to transfer.21 In another high-risk
atherosclerosis patient who underwent an anterior lateral
thigh flap for soft tissue reconstruction of the left lower
limb, the Visionsense system identified venous congestion
which would otherwise have been inconspicuous to clinical
examination. Following exploration, a thrombus was cleared
and the flap showed perfusion features similar to the
 Use of AR in Reconstructive Microsurgery Al Omran et al.

Table 2 Summary of studies with the use of augmented reality in reconstructive microsurgery

Study Country Oxford level Sample Mean Summary of methods
of evidence size age (y)
Nishimoto et al Japan 5 1 patient 74 An AR system was developed for
201620 simultaneous referring of the ICG
lymphography infrared images. The
infrared image was transmitted
wirelessly to glasses worn by the
surgeon enabling an overlaid real
operation field view while under-
taking a bilateral lower limb lym-
pho-venous anastomosis
Bigdeli et al Germany 4 8 patients 53.4 The Visionsense ICG-NIR-VA surgery
201621 system (Orangeburg, NY) can
overlay captured infrared and white
light imaging with highlighted per-
fusion providing the surgeon with a
virtual real-time anatomical view of
tissue as it is portrayed on the skin.
This system was applied to ten free-
flap surgeries (four ALT flaps; one
LD flap; one tensor fascia lata flap,
Main findings and conclusion
The surgeon was able to see both
fluorescently lymphatic vessels
and the operative view without
turning his head. Several aspects
of the system can be improved.
Development of AR technology
can be of benefit to the surgeon
The augmented perfusion reality
led to two additional interven-
tions in two patients; resection of
tip in a DIEP flap and a revision of
arterial anastomosis in an ALT
flap. The need to perform these
interventions would have been
inconspicuous by clinical assess-
ment alone. The system enhanced
decision making for flap design

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two DIEP flaps) in eight patients
Bosc et al France 4 12 patients NR AR was used for perforator map-
201711 ping before a DIEP breast recon-
struction by superimposing CT-
scans of the patients, converting
them to virtual layers and projec-
ting them onto AR smart glasses to
dissect out the perforator vessels
Cifuentes et al Chile 4 3 volunteers NR Using DIRT, three volunteers had
201828 both of their antero-lateral thighs
evaluated for the presence and lo-
cation of cutaneous perforators.
The obtained image of these “hot-
spots” was projected back onto the
volunteers’ thigh and a hand held
doppler was used to identify the
perforators
Pratt et al United Kingdom 4 6 patients 55.7 Bony, vascular, and soft tissue
201812 structures were delineated from
preoperative CT angiography scans
to form three dimensional images
that were converted to polygonal
models that could be used by sur-
geons via the HoloLens stereo head-
mounted display to aid navigation
and dissection in six subjects who
had lower limb perforator-based
reconstruction (three medial sural
artery perforator flaps and three
posterior tibial artery perforator
flaps)
and surgical procedures. A limi-
tation is of the constant need for
the surgeon to turn their head to
look at the monitor which displays
the findings of this AR technology
The ‘‘hands-free’’ smart glasses
with two stereoscopic screens
enabled the surgeon to better
delineate the operative anatomy
and raise the flaps. AR can be used
in preoperative planning
Hotspots of perforators were
identified in all six anterolateral
thighs and were successfully pro-
jected onto the skin. AR can be a
reliable method for transferring
the location of perforators iden-
tified by DIRT onto the thigh and
generating a reliable map of po-
tential perforators for flap raising
AR-generated models from CTA
scans can be used in reconstruc-
tive surgeries. The HoloLens
demonstrated to be a useful tool
that may reduce anesthetic time
and morbidity associated with
surgery and improve training and
provide remote support for the
operating surgeon

Abbreviations: ALT, anterior lateral thigh; AR, augmented reality; CT, computerized tomography; DIEP, deep inferior epigastric perforator; DIRT,
dynamic infrared thermography; LD, latissimus dorsi; NR, not reported.

surrounding tissues.21 Taken together, these examples illus-
trate how such an AR platform can salvage an operation.
However, a cited limitation included the need for the surgeon
to constantly turn to face the monitor rather than to physically
see images directly on the surface of the skin.21 Bosc et al
employed a method that may overcome this limitation; by
generating virtual images from preoperative CT scans that
were projected to AR smart glasses (and therefore did not need
to turn their heads to face a display), the authors were able to
dissect out perforator vessels in 12 patients undergoing DIEP
breast reconstruction.11 Other methods enlisted include the
HoloLens (Microsoft Corporation; Redmond, WA), which is a
head-mounted device that Pratt et al were able to use to exhibit
three-dimensional virtual models of vessels, tissue, and bony
landmarks onto the surgical site being operated on through AR
technology to not only correctly help identify perforators but
also help in the surgical dissection itself.12 Most of the studies
exploring the use of AR in reconstructive microsurgery employ
head-mounted devices or monitors to superimpose anatomi-
cal data onto the operative site. However, as has been reported
elsewhere,6 the limitations of these technologies include
reduced range of motion, lack of interference with the surgical

Journal of Reconstructive Microsurgery

 Table 3 Augmented reality microsurgery score of included studies in this systematic review

Criteria Quality of Correlation with Augmented reality features FINAL SCORE

recommendation educational
or clinical impact
Subcriteria Oxford level of evidence Improved Improved Clinical User-friendly Non-invasive Potential to Relative low Transferable
(inverse score applied) patient educational utility be Cost-effective barrier to to other (sub)
outcomes outcomes implement specialities
Available scores 1–5 0–2 0–2 0–3 0–1 0–1 0–1 0–1 0–1

Journal of Reconstructive Microsurgery

Nishimoto et al20 1 2 0 2 1 1 1 1 1 10
21
Bigdeli et al 2 2 0 3 1 1 1 1 1 12
12
Bosc et al 2 2 0 2 0 1 0 0 1 8
Cifuentes et al28 2 2 0 2 1 1 1 1 1 11
12
Pratt et al 2 2 0 2 1 1 1 0 1 10
Use of AR in Reconstructive Microsurgery
Al Omran et al.

Table 4 Methodological bias for the included studies using the protocol generated by Murad et al10

Author Year Does the patient(s) Was the Was the Were other Was there a Was there a Was follow-up Is the case(s) Overall
represent(s) the exposure outcome alternative challenge/ dose–response long enough described with Score
whole experience of adequately adequately causes that rechallenge effect? for outcomes sufficient detail(s) (out of 5)
the investigator ascertained? ascertained? may explain phenomenon? to occur? to allow other
(center) or is the the observation investigators to
selection method ruled out? replicate the
unclear to the ex- research or to
tent that other pa- allow practitioners
tients with similar to make inferences
presentations may related to their
not have been re- own practice?
ported?
Nishimoto et al20 2016 Unclear Yes Yes NA NA Yes Yes Yes 4
21
Bigdeli et al 2016 Unclear Yes Yes NA NA NA Yes Yes 4
Bosc et al11 2017 Unclear Yes Yes NA NA NA Yes No 3
Cifuentes et al28 2018 Unclear Yes Yes NA NA NA Yes Yes 4
Pratt et al 12 2018 Unclear Yes Yes NA NA NA Yes Yes 4

Abbreviation: NA, not applicable.

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 Use of AR in Reconstructive Microsurgery
field, and inadequate immersion. To overcome these limita-
tions, Cifuentes et al evaluated the use of projection-based AR
whereby digital data are physically superimposed by means of
projection onto the surface of the skin.28 The authors com-
bined the capabilities of a thermal camera and a portable
projector to project a thermal map of anterolateral thigh
perforators onto the surface of the skin on volunteers. This
study identified an average of five perforators in the area of
interest, which correlated 100% with hand-held Doppler find-
ings.28 The use of projector-based AR technology may reduce
the need for hardware and improve the surgeon’s experience.
Similar projection-based technologies were used in other
studies in this systematic review.15,22 In summary, the use
of AR in reconstructive microsurgery was achieved via the use
of spatial AR, hand-held, or head-mounted devices, which each
possess their own advantages and disadvantages (►Table 5),
and were related to the identification of perforator or lym-
phatic vessels, and all authors merit the use of AR in this field.
In addition to performing a descriptive analysis, quantitative
analysis was attempted through data pooling of the included
studies. However, due to the heterogeneity of the included
articles, such assimilation was not possible. As a result, a novel
scoring system was used to try and evaluate the use of the AR
application within each of the included studies and generally
within plastic surgery, with the higher the score, the higher the
utility of that AR platform. Such a clinical utility score has been
undertaken previously and provided a means of evaluation for
mixed model and heterogeneous studies, and has been taken in
the in the field of microsurgery26,27 For example, Pafitanis et al
devised a traffic light grading system to classify the utility of
different microvascular flowmetry devices into high “green,”
Table 5 Types of augmented reality applications used in this systematic review
Type of AR Description
application
Head-mounted A headpiece/visor/glasses that has information
devices displayed directly to the user on a screen
User may use gestures to direct
the virtual environment
Hand-held Nonwearable technology in which the user uses
devices his hands to manipulate and control but still
accumulates digital information and transfers
to a monitor or screen for the user to use
Spatial Technology that aims to enhance real-world
augmentation experience but without a user-specific experience
reality
May require projectors, mirrors,
and monitors to achieve its goal
Abbreviation: AR, augmented reality.
Al Omran et al.
moderate “yellow,” and low “red.”29 The scoring system used in
this systematic review (the ARM score) was based on this
scoring system. Upon completion of data gathering, the authors
identified several objective and subjective criteria and subcri-
teria to evaluate the AR platforms of the included studies. A
global consensus was subsequently generated to form the ARM
score and what the components of the score would be and how
scores would be partitioned. The ARM score with a three-way
“traffic light” classification system was created from this
process to provide a measure of the clinical utility of the
microsurgical AR application in the included studies, at least
on face value (face validity; ►Table 2).
The ARM score consists of three major criteria, subdivided
to create a total of ten subcriteria in total to give a cumulative
score of 17 (►Table 3). A score of 1–8 was classified as having
“low” (red) clinical utility, a score of 9–12 classified as
“moderate” (yellow), and a score of 13–17 classified as
“high” (green). The major criteria comprise a mix of objective
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and subjective features including: (1) quality of recommen-
dation: this is based on the Oxford level of evidence and
potential scores ranges from 1 to 5, where the higher the level
of evidence, the higher the score, and thus, the inverse value
of the level of evidence was given as the score. For example, a
level of evidence of two would yield a score of 4, while a level
of evidence of five would yield a score of 1. (2) Correlation
with educational or clinical impact: this was categorized as
whether the AR application was reported to have improved
patient outcomes (as per authors’ interpretation) or have
improved educational outcomes (as per authors’ interpreta-
tion). Finally, the AR features were evaluated: this included
whether the AR device possessed clinical utility, which was
Potential limitation
Costly to buy and implement
May rely on additional features such as Wi-Fi,
virtual software which may not be available
May distract the user from the real-world environment
May capture, private, or confidential data that was
not intended to be captured
Costly to buy and implement
May rely on additional features such as Wi-Fi,
virtual software which may not be available
User must physically hold the device which
depending on the task can be burdensome
Costly to buy and implement
May rely on additional features such as Wi-Fi,
virtual software which may not be available
Could be a distractor to those on the surrounding
environment who are performing another task
(e.g., another surgeon performing another
part of the procedure)
Journal of Reconstructive Microsurgery
Use of AR in Reconstructive Microsurgery Al Omran et al.
further categorized into (1) useful but user can manage
without it; (2) eased the operation for the user; and (3)
salvaged the operation, as was shown by the AR system as
reported by Bigdeli et al.21 Other features in this category
included whether the AR application was user-friendly,
noninvasive or cost-effective had a relatively low barrier to
implementation and was transferable to other subspecial-
ities. The latter subcriteria are more subjective and therefore
were awarded less value.
In summary, the ARM scores yielded values of 8 to 12
(►Table 3). Scoring of the “AR features” criteria may warrant
further description as this remained the most subjective
element of the ARM score. Bosc et al received a score of 8 for
their article,11 losing a point for not being user-friendly and not
having low barriers to implementation as deemed by the
authors. Although this article was reported in French, the
authors justified not providing a score of 1 by the lack of
clarity, which was provided after review by two of the authors
proficient in French (C.S. and T.M.B.). Despite attempted email
correspondence with the author, further clarity was not
provided and so a 0 was provided for these categories as it
was presumed that sophisticated programming would be
warranted to effectively to introduce this AR application into
clinical practice. The other included articles were all valued as
having fulfilled the criteria for scoring in the associated sub-
criteria and so were awarded a score of 1. The study that was
regarded as having the highest clinical value was that of Bigdeli
et al.21 This study demonstrated a simple and effective means
by which AR can be useful in salvaging a free flap and that can
be used in other areas of reconstructive microsurgery. The
studies of Bosc et al11 and Pratt et al12 were conceptually very
good but required digitalization of the CT images prior to
incorporation into the AR technology; as a result, these may
not be widely applicable and so were viewed as having a higher
barrier to implementation.
In addition to the obvious benefits of facilitating a swifter
operation, fewer complications and less strenuous time for
the surgeon, the benefits of AR application can also educate
trainees. None of the included studies demonstrated the
educational value of AR technology, which should not
be understated. For example, Greenfield et al detailed a
method whereby a surgeon in Beirut was able to help guide
and demonstrate the steps in a complex hand reconstruction
to a surgical team in Gaza for an 18-year-old male who
developed a large burn contracture to the hand.13 Using a
simple set up of cameras, monitors, and Proximie software
(Proximie, London, UK), the surgeon in Beirut was able to
communicate to the operating surgeon in Gaza by means of a
pointer to demonstrate key steps which the operating sur-
geon could see on a monitor. This helped to reconstruct the
left hand of this patient, and further highlighted how a
reproducible, simple, and low cost AR system may not only
treat patients but could also train surgeons from afar and
may help to reduce structural inequities in global medical
care.13 In addition, within the field of general plastic surgery,
a projection-based AR platform was used to facilitate local
flap design and implementation. The authors discuss how
this system may be used on patients to improve local flap
Journal of Reconstructive Microsurgery
surgery and also to educate plastic surgery trainees with
regards to flap design. Since such systems may be used in
reconstructive microsurgery, the educational elements of AR
technology may be an area of focus in future research.
Barriers to the rapid implementation of AR in plastic
surgery do exist (of which some are noted in ►Table 5).
Many of these barriers parallel those found in other
enhanced technologies such as surgical robotics and mobile
and surgical robotics devices.30 Similar to how mobile
phones may be disruptive, AR devices may disturb surgeons
and prevent a swift response if an unexpected event occurs.
Such findings have been shown in surgeons whom, when
using AR to perform an endoscopic task, had slower reaction
times and were not as able to detect a foreign object placed in
the operative field.31 These data indicate that the integration
of AR technology into clinical practice may subject a surgeon
to inattentional blindness.31
The implementation of novel technology in theater may raise
Downloaded by: Queen Mary, University of London. Copyrighted material.
the cost of operating times and procedures. For several proce-
dures, the utility of AR would perhaps not outweigh
the additional expense of introducing these technologies into
clinical practice. As more devices enter market, exploration of
the utility to the surgeons, patients, and hospital managers must
be measured with the increased costs of implementation.32
Although a cost-utility analysis was not performed in any of
the included studies in this systematic review, and the fact that
although some devices may be costly, it has been shown that
although AR may have a high initial cost (to buy and set up the
AR system), it may be more cost-effective than alternative non-
AR measures in the long term.33 Taken together, cost-utility
analyses will need to be conducted to determine whether the
price of AR systems warrants their use.
The privacy and security considerations of AR devices
themselves merit their own scrutiny. The immersive expe-
rience AR platforms could in theory lure the operator into
believing that certain items are present in the real world
leading to an unintended action that could physically harm
patients. Although this was not reported in any of the
studies in this systematic review, developing AR applica-
tions need to study and prevent these types of harmful
possibilities. In the event of malfunction, surgeons would
need to quickly turn off the AR feature and resume the
clinical task without AR. This may be difficult to achieve,
especially since some devices are integrated into the oper-
ation (for example a head-mounted device or projected
onto the patient); an investigation to improve these features
should therefore be considered.
Finally, as with all patient centered data, data manage-
ment and confidentiality are a significant barrier to the
incorporation of AR interfaces into the clinical environment.
Physicians have a duty of care and need to be aware of legal
and ethical requirements when using technology to record,
store, or transfer patient data. Encryption strategies may be
formed as a solution to this issue but may not mitigate
against data hijacking.34 Taken together, with a plethora of
varying healthcare networks globally, it is likely that the
implementation of AR platforms may be achieved in different
systems depending on the level of security and rules in place.
 Use of AR in Reconstructive Microsurgery
This systematic review is not without limitations. On an
outcome level, this study was limited by the variable, hetero-
geneous outcomes reported that prevented systematic synthe-
sis and meta-analysis of findings. The lack of reporting of a set
number of outcomes frequently hinders systematic reviews.
Core outcome sets that standardize reporting have offered a
solution in surgical studies,35,36 and the incorporation of such
outcome sets in AR and VR studies should be explored as it is
anticipated that this would improve the quality of studies in this
field. Unfortunately, the quality of the included studies in this
systematic review with all articles being case-reports or case
series and without a comparator. These findings are not sur-
prising due to the novelty of AR in plastic surgery and in surgery
as a whole; it is expected that the majority of studies would be
feasibility studies and would therefore naturally constitute case
reports and case-series before progressing to case-control,
cohort studies, and randomized control trials.37 Finally, the
ARM scoring system generated was based on previous studies,
including those in microsurgery,29 and consensus was generat-
ed for the included criteria and subcriteria, and the generation
of scores but nonetheless it is a scoring system that has not been
fully validated and tested and may be subject to bias. Addition-
ally, this scoring system may be affected more heavily by
reporting of the authors, with poorly reported outcomes
resulting in missed scores while in reality the score should
be higher. Development of a core outcome dataset may offer a
solution.
Conclusion
The application of AR in reconstructive surgery is a new and
exciting field. This systematic review provides a comprehensive
and up-to-date evaluation of the use of AR in reconstructive
microsurgery. The evidence from the included studies demon-
strates that AR has the potential to be a powerful tool to
reconstructive microsurgeons and may facilitate better out-
comes for patients. However, the use of AR in reconstructive
microsurgery is still novel. The majority of studies in this field
are feasibility studies and further work is needed before its
widespread application can be adopted. Additionally, the qual-
ity of the evidence of included studies was poor, and future
work in this field should focus on well-constructed outcome
studies (with a non-AR comparator) that must be undertaken to
validate the power of AR in the different subspecialties of plastic
surgery as well as development of potential core outcome sets
that enable acquisition of heterogeneous data that for adequate
comparison across the studies. Future work should also explore
solutions to the barriers that prevent implementation of AR in
the surgical setting. Similar issues once existed for robotic
surgery across many surgical disciplines, but the challenges
were overcome and robotic surgery has become common-
place.29,38–43 There should be no reason why the use of AR in
reconstructive microsurgery should not follow a similar natural
history and is expected to be welcomed into clinical practice if
the hurdles that limit its use can be addressed.
Funding
None.
Al Omran et al.
Conflict of Interest
None declared.
References
1 Fida B, Cutolo F, di Franco G, Ferrari M, Ferrari V. Augmented
reality in open surgery. Updates Surg 2018;70(03):389–400
2 Wong K, Yee HM, Xavier BA, Grillone GA. Applications of aug-
mented reality in otolaryngology: a systematic review. Otolar-
yngol Neck Surg 2018:019459981879647
3 Kim Y, Kim H, Kim YO. Virtual reality and augmented reality in
plastic surgery: a review. Arch Plast Surg 2017;44(03):179–187
4 Ramachandran S, Ghanem AM, Myers SR. Assessment of micro-
surgery competency-where are we now? Microsurgery 2013;33
(05):406–415
5 Clark AD, Barone DG, Candy N, et al. The effect of 3-dimensional
simulation on neurosurgical skill acquisition and surgical perfor-
mance: a review of the literature. J Surg Educ 2017;74(05):828–836
6 Sayadi LR, Naides A, Eng M, et al. The new frontier: a review of
augmented reality and virtual reality in plastic surgery. Aesthetic
Downloaded by: Queen Mary, University of London. Copyrighted material.
Surg J 2019;39(09):1007–1016
7 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group.
Preferred reporting items for systematic reviews and meta-anal-
yses: the PRISMA statement. PLoS Med 2009;6(07):e1000097
8 Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal
tool for systematic reviews that include randomised or non-
randomised studies of healthcare interventions, or both. BMJ
2017;358:j4008
9 Higgins JPTGS. Cochrane handbook for systematic reviews of inter-
ventions version 5.1.0. (updated March 2011). Available at: https://
training.cochrane.org/handbook. Accessed November 27, 2018
10 Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological
quality and synthesis of case series and case reports. BMJ Evid
Based Med 2018;23(02):60–63
11 Bosc R, Fitoussi A, Pigneur F, Tacher V, Hersant B, Meningaud J-P.
[Identification of perforating vessels by augmented reality: ap-
plication for the deep inferior epigastric perforator flap]. Ann Chir
Plast Esthet 2017;62(04):336–339
12 Pratt P, Ives M, Lawton G, et al. Through the HoloLens™ looking
glass: augmented reality for extremity reconstruction surgery
using 3D vascular models with perforating vessels. Eur Radiol Exp
2018;2(01):2
13 Greenfield MJ, Luck J, Billingsley ML, et al. Demonstration of the
effectiveness of augmented reality telesurgery in complex hand
reconstruction in Gaza. Plast Reconstr Surg Glob Open 2018;6
(03):e1708
14 Zhu M, Liu F, Zhou C, et al. Does intraoperative navigation improve
the accuracy of mandibular angle osteotomy: comparison be-
tween augmented reality navigation, individualised templates
and free-hand techniques. J Plast Reconstr Aesthet Surg 2018;71
(08):1188–1195
15 Sayadi LR, Chopan M, Maguire K, et al. A novel innovation for
surgical flap markings using projected stencils. Plast Reconstr
Surg 2018;142(03):827–830
16 Zemirline A, Agnus V, Soler L, Mathoulin CL, Obdeijn M, Liver-
neaux PA. Augmented reality-based navigation system for wrist
arthroscopy: feasibility. J Wrist Surg 2013;2(04):294–298
17 Qu M, Hou Y, Xu Y, et al. Precise positioning of an intraoral
distractor using augmented reality in patients with hemifacial
microsomia. J Craniomaxillofac Surg 2015;43(01):106–112
18 Lin L, Shi Y, Tan A, et al. Mandibular angle split osteotomy based
on a novel augmented reality navigation using specialized robot-
assisted arms–A feasibility study. J Craniomaxillofac Surg 2016;
44(02):215–223
19 Chimenti PC, Mitten DJ. Google glass as an alternative to standard
fluoroscopic visualization for percutaneous fixation of hand frac-
tures: a pilot study. Plast Reconstr Surg 2015;136(02):328–330
Journal of Reconstructive Microsurgery
 Use of AR in Reconstructive Microsurgery Al Omran et al.
20 Nishimoto S, Tonooka M, Fujita K, et al. An augmented reality
system in lymphatico-venous anastomosis surgery. J Surg Case
Rep 2016;2016(05):rjw047
21 Bigdeli AK, Gazyakan E, Schmidt VJ, et al. Indocyanine green
fluorescence for free-flap perfusion imaging revisited: advanced
decision making by virtual perfusion reality in visionsense fusion
imaging angiography. Surg Innov 2016;23(03):249–260
22 Schreiber JE, Stern CS, Garfein ES, Weichman KE, Tepper OM.
A novel approach to surgical markings based on a topographic
map and a projected three-dimensional image. Plast Reconstr
Surg 2016;137(05):855e–859e
23 Mitsuno D, Ueda K, Itamiya T, Nuri T, Otsuki Y. Intraoperative
evaluation of body surface improvement by an augmented reality
system that a clinician can modify. Plast Reconstr Surg Glob Open
2017;5(08):e1432
24 Vávra P, Roman J, Zonča P, et al. Recent development of augmented
reality in surgery: a review. J Healthc Eng 2017;2017:4574172
25 Bosc R, Fitoussi A, Hersant B, Dao TH, Meningaud JP. Intraoperative
augmented reality with heads-up displays in maxillofacial sur-
gery: a systematic review of the literature and a classification of
relevant technologies. Int J Oral Maxillofac Surg 2019;48(01):
132–139
26 Pafitanis G, Raveendran M, Myers S, Ghanem AM. Flowmetry
evolution in microvascular surgery: a systematic review. J Plast
Reconstr Aesthet Surg 2017;70(09):1242–1251
27 Pluye P, Gagnon M-P, Griffiths F, Johnson-Lafleur J. A scoring system
for appraising mixed methods research, and concomitantly apprais-
ing qualitative, quantitative and mixed methods primary studies in
mixed studies reviews. Int J Nurs Stud 2009;46(04):529–546
28 Cifuentes IJ, Dagnino BL, Salisbury MC, Perez ME, Ortega C,
Maldonado D. Augmented reality and dynamic infrared thermog-
raphy for perforator mapping in the anterolateral thigh. Arch Plast
Surg 2018;45(03):284–288
29 Kawal T, Sahadev R, Srinivasan A, et al. Robotic surgery in infants
and children: an argument for smaller and fewer incisions. World
J Urol 2019
30 Selber JC. Can I make robotic surgery make sense in my practice?
Plast Reconstr Surg 2017;139(03):781e–792e
Journal of Reconstructive Microsurgery
View publication stats
31 Dixon BJ, Daly MJ, Chan H, Vescan AD, Witterick IJ, Irish JC. Surgeons
blinded by enhanced navigation: the effect of augmented reality on
attention. Surg Endosc 2013;27(02):454–461
32 Hupp JR. Advanced technology–hammers looking for nails. J Oral
Maxillofac Surg 2013;71(03):465–466
33 Davis CR, Rosenfield LK. Looking at plastic surgery through Google
Glass: part 1. Systematic review of Google Glass evidence and the
first plastic surgical procedures. Plast Reconstr Surg 2015;135
(03):918–928
34 Haynes CL, Cook GA, Jones MA. Legal and ethical considerations in
processing patient-identifiable data without patient consent:
lessons learnt from developing a disease register. J Med Ethics
2007;33(05):302–307
35 Agha RA, Borrelli MR, Vella-Baldacchino M, Thavayogan R, Orgill
DP; STROCSS Group. The STROCSS statement: strengthening the
reporting of cohort studies in surgery. Int J Surg 2017;46:
198–202
36 Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP;
PROCESS Group. The PROCESS 2018 statement: Updating Consen-
sus Preferred Reporting Of CasE Series in Surgery (PROCESS)
guidelines. Int J Surg 2018;60:279–282
Downloaded by: Queen Mary, University of London. Copyrighted material.
37 Kapoor MC. Types of studies and research design. Indian J Anaesth
2016;60(09):626–630
38 Mucksavage P, Kerbl DC, Lee JY. The da Vinci(®) Surgical System
overcomes innate hand dominance. J Endourol 2011;25(08):
1385–1388
39 Weinstein GS. Transoral robotic surgery and the standard of care.
Int J Radiat Oncol Biol Phys 2017;97(01):4
40 Selber JC. Robotic nipple-sparing mastectomy: the next step in the
evolution of minimally invasive breast surgery. Ann Surg Oncol
2019;26(01):10–11
41 Diana M, Marescaux J. Robotic surgery. Br J Surg 2015;102(02):
e15–e28
42 Zirafa CC, Romano G, Key TH, Davini F, Melfi F. The evolution of
robotic thoracic surgery. Ann Cardiothorac Surg 2019;8(02):
210–217
43 Nadjmi N. transoral robotic cleft palate surgery. Cleft Palate
Craniofac J 2016;53(03):326–331