Extended reality for perforator visualization in deep inferior epigastric perforator autologous breast reconstruction: A systematic review

BACKGROUND: Extended Reality (XR) technology is rapidly advancing and has shown promise in improving perioperative outcomes across various surgical specialties.

OBJECTIVE: This systematic review aimed to evaluate the use of XR for perforator vessel visualization in autologous breast reconstruction.

METHOD: A systematic search was conducted following PRISMA guidelines, consulting Embase, Medline (Ovid), Web-of-Science, Cochrane, and Google Scholar on June 23, 2025. Articles describing the use of XR for perioperative perforator visualization in free flap breast reconstruction were included. Outcome measures included perforator identification rate, virtual model construction time, preoperative planning duration, flap dissection time, usability, complications, and costs.

RESULTS: Ten articles were included, all focused on XR in deep inferior epigastric perforator (DIEP) flap breast reconstruction. Three XR modalities were identified: virtual reality (VR), augmented reality (AR) projection, and AR glasses. Perforator identification using XR ranged from 61.7 % to 100 %, with AR outperforming handheld Doppler ultrasound (US) in several studies. XR use decreased operative time, with AR reducing intraoperative perforator localization time from 20 min using handheld Doppler US to 2.3 min. The use of XR did not result in significant additional costs, and no differences in complication rates were identified.

CONCLUSION: XR may assist surgeons in perioperative perforator visualization during DIEP flap breast reconstruction by enhancing anatomical understanding. However, current evidence is constrained by small, low-quality studies and comparisons with handheld Doppler rather than the gold standard computed tomography angiography (CTA). Whether XR offers clinically meaningful advantages over conventional CTA imaging remains uncertain, as this was not explored in the included articles. Larger, high-quality comparative studies are needed to establish its true clinical value.