Journal of Plastic, Reconstructive & Aesthetic Surgery 82 (2023) 255–263

Review

The application of augmented reality in

]]
]]]]]]
]]

plastic surgery training and education:

A narrative review
Yi Min Khoong 1, Shenying Luo 1, Xin Huang, Minxiong Li,
⁎
Shuchen Gu, Taoran Jiang, Hsin Liang, Yunhan Liu, Tao Zan

Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong
University School of Medicine, Shanghai, PR China

Received 19 December 2022; Accepted 8 April 2023

KEYWORDS Summary Continuing problems with fewer training opportunities and a greater awareness of
Immersive patient safety have led to a constant search for an alternative technique to bridge the existing
technology; theory–practice gap in plastic surgery training and education. The current COVID-19 epidemic
Augmented reality; has aggravated the situation, making it urgent to implement breakthrough technological in­
Plastic surgery itiatives currently underway to improve surgical education. The cutting edge of technological
training; development, augmented reality (AR), has already been applied in numerous facets of plastic
Plastic surgery surgery training, and it is capable of realizing the aims of education and training in this field. In
education; this article, we will take a look at some of the most important ways that AR is now being used in
Telementoring plastic surgery education and training, as well as offer an exciting glimpse into the potential
future of this field thanks to technological advancements.
© 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Contents

. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
. The application of AR in plastic surgery training and education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
. Anatomical holograph in real time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

⁎
Correspondence to: Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University
School of Medicine, 639 Zhizaoju Road, Shanghai 200011, PR China.
E-mail address: zantao@sjtu.edu.cn (T. Zan).
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.bjps.2023.04.033
1748-6815/© 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
 Y.M. Khoong, S. Luo, X. Huang et al.

. Real-time interactive telementoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

. Surgical procedure video documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
. Enhanced intraoperative communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
. AR-assisted robotic surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
. Other forms of immersive technology: VR and MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
. Funding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
. Ethical approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
. CRediT authorship contribution statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
. Declaration of Competing Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
. References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

In plastic surgery training and education, the development
of fine surgical skills and the acquisition of a comprehensive
understanding of human anatomy are regarded as of the
utmost importance. Without years of hands-on clinical ex­
perience and the guidance of seasoned instructors, none of
these would have been possible. With decreased training
hours and the growing importance of patient safety in
plastic surgery, we seek a novel educational modality that
allows for greater flexibility in training to bridge the gap
between theory and practice without sacrificing quality.
The recent COVID-19 outbreak has prompted a massive di­
gital transformation in the health care industry, and plastic
surgery education has not been exempted from this trend.
Immersive technologies such as virtual reality (VR), aug­
mented reality (AR), and mixed reality (MR) have made sig­
nificant advancements over the past decade. These
technologies have enabled more sophisticated and realistic
teaching and learning opportunities in plastic surgery edu­
cation.1–7
We chose to focus on the use of AR due to its ability to
produce a semi-immersive experience for the user by super­
imposing digital objects or data onto the user's view of the real
world. The real world remains at the center of the user's ex­
perience despite the addition of virtual elements, which can
range from direct perceptions of anatomical features via ima­
ging projection to the recreation of realistic tactile surgical
experience via an advanced haptic device. All these qualities
are extremely advantageous for the training of plastic surgery
specialists, who must be proficient in both delicate artwork and
accurate anatomical identification.1,8
In this article, we will evaluate the current use of AR in
plastic surgery education and how its use in other surgical
specialties may have contributed to its wider and more ef­
fective use in plastic surgery.
Method
A narrative review was conducted of the current literature
discussing the application of AR in plastic surgery training and
education. A literature search was performed using PubMed
for English-language publications between January 1, 1995,
and October 15, 2022, with a focus on the use of AR in plastic
surgery education. This includes the subspecialties of plastic
surgery including reconstructive surgery, esthetic surgery,
microsurgery, and maxillofacial surgery. The final Medical
Subject Heading (MeSH) terms included (("Surgery, Plastic/
education"[Mesh] OR "Surgery, Plastic/instrumentation"[Mesh]
OR "Reconstructive Surgical Procedures/education"[Mesh] OR
"Reconstructive Surgical Procedures/instrumentation"[Mesh]
OR "Microsurgery/education"[Mesh] OR "Microsurgery/
instrumentation"[Mesh] OR "Orthognathic Surgical Procedures/
education"[Mesh] OR "Orthognathic Surgical Procedures/
instrumentation"[Mesh]) AND ("Augmented Reality"[Mesh] OR
"Smart Glasses"[Mesh] OR "Telemedicine"[Mesh] OR "Simulation
Training"[Mesh])). The initial search yielded 266 papers, whose
titles and abstracts were evaluated by one author for re­
levance. Using the reference lists of relevant articles and the
"Similar articles" section of PubMed, seven additional pub­
lications were chosen by hand and considered appropriate for
further evaluation.
A total of forty articles met the initial inclusion criteria and
were deemed eligible after the initial screening. After two
authors independently reviewed these full-text articles, 17
were deemed eligible. To make the discussion more compre­
hensive, we have included applications that are not intended
for educational purposes in plastic surgery but may be ad­
vantageous and applications used in other relevant surgical
specialties that may offer insights for the potential develop­
ment of plastic surgery. Therefore, we have included a dis­
cussion of the current limitations and potential improvements
that can be made to the currently available AR devices.
The application of AR in plastic surgery training
and education
Head-mounted displays (HMDs) and fixed cameras are the
two forms of AR devices currently used in plastic surgery.
HMD is a lightweight headwear with a small screen that acts
as a portal for continuous and immediate information ac­
cess with minimal visual distraction in the upper right
corner. Particularly, its built-in camera and hands-free fea­
tures have piqued the interest of surgeons because of the
ease of image capture, video recording, and data access
through voice and motion commands.9,10 This led to its first
application in plastic surgery, a bilateral blepharoplasty, in
2013.4 Concerns remain, however, regarding neck strain,
vision disruption, and instability during body move­
ment.4,6,10 Fixed camera systems, which rely on a simple

256
 Journal of Plastic, Reconstructive & Aesthetic Surgery 82 (2023) 255–263
in-theater setup consisting of fixed cameras, capture cards,
and a laptop or tablet placed in a nonobstructive location,
may be a viable alternative for addressing such diffi­
culties.6,11,12
In the parts that follow, we shall investigate how AR can
be of assistance with the education and training of modern
plastic surgeons.
Anatomical holograph in real time
Inexperienced trainees commonly have trouble picturing
the course of anatomical structures in actual patients based
on patient imaging and combining images from different
imaging modalities that reflect the same patient, especially
in those with anatomical variations. However, this is a
crucial skill that every plastic surgeon needs to acquire as it
leaves a direct impact on preoperative planning and sur­
gical outcomes.
Although computed tomography angiography (CTA) is the
current gold standard for perforator mapping in flap sur­
geries, surgeons are frequently left to their own imagina­
tion when superimposing these 3D reconstructed images
onto the patients. Pereira et al.13 reported accurate iden­
tification of the dissection path map for a circumflex iliac
artery perforator flap made possible by a smartphone-based
AR application that transfers 3D reconstruction images from
the CTA (ARM-PS). This application not only enhanced the
trainees' ability to view the dissection map, but also re­
duced the flap harvesting time by 20%.
AR technology has also been utilized in conjunction with
more advanced imaging modalities, including indocyanine
green (ICG) or photoacoustic imaging, which may have been
more advantageous for imaging of more superficial, smaller
vascular branches. For instance, using the HMD device
MOVERIO Smart Glass BT-30E, surgeons were able to view
ICG lymphography or photoacoustic lymphangiography (PAL)
images directly on the patients’ body surface.14,15 The su­
perimposition of computer-generated images over the sur­
gical site provides precise direct visibility of the perforator
course, allowing for a better appreciation of the flap design
by the trainees, which is essential for training their pre­
operative decision-making skills and enabling them to make
an informed decisions regarding the incision site that would
yield the best reconstructive results.
Real-time interactive telementoring
To become a surgeon, one needs to "stand on the shoulders
of giants," and the development of new surgical methods
typically involves building on the previous ones.
Unfortunately, surgical trainees may not have the best view
of operation due to limited visibility and difficulties with
positioning. However, with a HMD like Google Glass, trai­
nees can readily observe surgical procedures "through the
eyes" of an expert.4 This is especially helpful in learning
procedures with an intrinsically restricted observer's per­
spective, including rhinoplasty, blepharoplasty, and per­
forator dissection during flap raising. Google Glass has also
created a global platform for surgeons in the United States
to reach out to surgeons in less developed countries with
specialist shortages like Mozambique, to provide real-time
257
assistance and training opportunities on a range of re­
constructive surgery. This has allowed surgeons in Mo­
zambique to receive assistance and training opportunities
on a greater variety of procedures.7 However, due to the
significant limitations that are associated with the currently
available wearable technology, such as instability when
motion is introduced, some surgeons may prefer the use of
fixed camera AR systems like Proximie.7,12
Proximie is a cloud-based AR platform that complies with
the Health Insurance Portability and Accountability Act
(HIPAA) and the General Data Protection Regulation (GDPR),
with the intention of promoting global surgical connectivity
and collaboration by combining machine learning, artificial
intelligence (AI), and AR. Recent occurrences have piqued
our interest in it as a result of its rapid adoption and ex­
traordinary results across various surgical special­
ties.6,11,16,17 Utilizing this AR technology, medical experts
across the globe were able to "scrub in" and provide surgical
guidance. Surgical telementoring is no longer limited to
providing real-time verbal guidance; rather, it enables sur­
geons to "reach into" the operating field to provide high-
fidelity, precise, and exact instruction using interactive
tools like a 3D hand, pointer, drawings, and even the su­
perimposition of crucial patient imaging.6,11 It connects
surgeons from all over the world, regardless of their ex­
perience, resources, financing, time, or travel constraints,
which is especially beneficial during the present pandemic.
This is a significant step toward ensuring that everyone has
access to the necessary medical care.
In plastic surgery, Proximie had assisted remote surgeons
in Beirut in guiding local doctors in Gaza through a com­
plicated hand reconstruction in a step-by-step fashion.6
Collaboration with Global Smile Foundation, an organiza­
tion for cleft outreach that consists of multidisciplinary
cleft clinicians and offers a global educational program for
the training of cleft providers,11 has demonstrated its ef­
fectiveness as a guidance tool. Two Peruvian surgeons
working under the supervision of remote surgeons from the
United States exhibited significant improvements in all as­
pects of cleft lip repair after a 13-month offshore AR-based
cleft surgery curriculum with only three semiannual site
visits (Figure 1). Importantly, the high accuracy and preci­
sion of this platform has been demonstrated by its anthro­
pometric landmarks for nasolabial repair to within 1 mm.11
With such sophisticated technology, every trainee's action is
constantly monitored. Having the knowledge that assis­
tance is always close at hand is a great confidence booster
that helps them learn how to handle challenging circum­
stances independently while maintaining a sense of calm
and control.11
Additionally, the limited number of surgical trainees
permitted to participate in each surgical session is a
common obstacle for traditional in-theater didactic
methods, but this could be easily resolved with Proximie, as
Mughal et al.12 recently demonstrated by creating an in­
teractive live surgery video series on the topic of micro­
surgical free flap reconstructions in the lower limb using
Proximie. Not only could consultant surgeons interact with
their observing trainees during surgical demonstrations in
real-time using the platform's speech and AR annotation
tools, but the platform's ability to superimpose anatomical
diagrams on the operation field could facilitate theoretical
 Y.M. Khoong, S. Luo, X. Huang et al.
Figure 1 The intraoperative augmented reality platform allowed a remote surgeon to "scrub in" and assist with an operation in
another country. This figure depicts how audio and video from the overseas surgery and the virtual field of the remote surgeon were
combined into a single AR livestream.
Reproduced with permission from11. Copyright © 2020 by the American Society of Plastic Surgeons.
discussion and the highlighting of essential anatomical
features and landmarks. This is particularly important for
establishing constant engagement between the operating
surgeon and the observed trainees by providing enhanced
and immediate feedback. And the best part is that the
trainees did not even need to be physically present to
benefit from surgical teaching.12
Surgical procedure video documentation
Surgical recordings, especially those captured with HMD
devices, are an effective educational tool since they not
only show trainees the intervention from the perspective of
the operating surgeon, but also provide crucial information
regarding anatomy and procedure. Recording technology
equipped with AR also enables simpler documentation of
surgical recordings that may be stored in an online library
and viewed on demand.12 Access to detailed records of a
variety of surgical procedures, including those involving
exceptional circumstances, is an excellent resource for
training the trainees in situation awareness and preparing
them to deal with unanticipated changes in clinical settings
after weighing relevant factors. Those involving uncommon
and complex conditions, in particular, could also encourage
genuine debate among the world's finest experts, leading to
potential breakthroughs in surgical approach.
It is possible that first-person recordings with Google
Glass could add value to the portfolio of workplace-based
assessments (WBAs) as evidence of clinical competency.18
This is due to the fact that first-person recordings with
Google Glass provide convenient and superior visualization
than conventional third-person vantage recordings.19 WBAs
could be better utilized by including these recordings,
which could also provide trainees with a second learning
opportunity by allowing them to reflect on their own per­
formance while also receiving evaluation and personalized
feedback from their supervisor, resulting in more effective
progress. Instead of being treated as a tick-box exercise,20
WBAs could be utilized more effectively by including these
recordings. This would enable trainees to acquire a critical
258
competency for their surgical career development: the
ability to reflect on their own work and determine what
they need to know to fill any knowledge gaps.12 That way,
we would move beyond the traditional surgical training
strategy of "See one, Do one, Teach one" and instead im­
plement Proximie's 3P technique of "Prepare, Perform,
Perfect," which may be more effective and appropriate for
re-engaging trainees in routine surgical procedures in this
digital era.21
Enhanced intraoperative communication
Considering the trainee's vision field will be different from
that of the supervisor due to the positioning during opera­
tion, there may be moments when it is challenging for the
trainee to fully comprehend the instruction being given.
HMD AR device could be put in good use in overcoming this
challenge. Even though they will be standing in different
places, the supervisor and the assisting trainee will be
sharing the same operative field on the HMD, making it
possible for any concerns or uncertainties to be voiced and
communicated in a timely manner.4
Similar circumstances are also encountered in microsurgery,
which typically involves the use of a standard operating mi­
croscope and in which the student is positioned opposite the
supervisor. Although the use of exoscopes in conjunction with
polarized 3D glasses has made it possible for everyone in the
operating room to view the same high-definition magnified 3D
image on the monitor,22–24 issues relating to steep learning
curves,23 ergonomics, and the level of comfort experienced by
surgeons have not yet been resolved.25 In this context, a recent
piece of research suggested that the usage of exoscopes in
conjunction with Moverio Smart Glasses may be beneficial.25
That way, the surgical procedure can be observed by both the
supervisor and the assisting trainees, with the latter having a
mirrored view to facilitate effective communication without
compromising the level of comfort. This communication could
be enhanced even further by the AR's feature that allows si­
multaneous viewing of patients' imaging or notes while as­
sisting, without jeopardizing the sterility of the surgical field.
 Journal of Plastic, Reconstructive & Aesthetic Surgery 82 (2023) 255–263
Figure 2 Augmented reality-assisted robotic surgery. (A) An augmented reality projector was used to overlay virtual mandibular
region information (anatomical structures and drilling tunnels) with the dog's actual mandibular region. (B) The actual drilling was
performed along the axis of the virtual tunnels. (C) The osteotomy plane was finally obtained by cutting along all of the tunnels.
Reprinted with permission from Springer Nature1 © Springer Nature, 2017.
AR-assisted robotic surgery
While AR gives surgeons an "augmented surgical eye" that
allows projection of virtual images onto the actual pa­
tient,26 robotic surgery could be seen of as an "augmented
surgical hand" that helps with fine tremors and motion
scaling,27,28 which is a common issue for plastic surgery
trainees performing microsurgery or osteotomy.
As mandibular osteotomy is a surgical procedure that ne­
cessitates sensitive force perception, high stability, and accu­
racy, it is frequently seen as an unattainable assignment for
inexperienced trainees.1 To effectively train them, one must
relinquish control and allow trainees to perform and experience
surgery on their own, however, without jeopardizing patient
safety. To achieve that, Shi29 and Zhou et al.1 integrated the
use of a robotic surgical system with AR, which helps to assure
an accurate osteotomy plane even when performed by in­
experienced surgeons. This robot system features a haptic
feedback mechanism that monitors the drilling force to guar­
antee a risk-free osteotomy1 (Figure 2).
Microsurgery training is typically lengthy, tremoring is thus
unavoidable when anastomosing delicate vessels, particularly
when performed by inexperienced trainees. Nevertheless, with
the assistance of robotic surgery equipped with ergonomically
designed consoles and tremor filtering, plastic surgery trainees
may be able to become familiar with microsurgery more quickly
and in greater comfort despite its high skill requirements and
lengthy operating time.28,30
Other forms of immersive technology: VR
and MR
With VR, the user's vision of the real world is completely
blocked out by the VR headset, allowing them to completely
immerse themselves in a computer-generated virtual en­
vironment that closely resembles reality, which may be
beneficial in helping trainees focus more intently on the
tasks at hand during training.8,31 Touch Surgery is a free
smartphone application based on cognitive task analysis,
which has been demonstrated to be effective as a
259
supplementary training tool,32–34 even in low-income coun­
tries.33 This surgical simulation application currently has 43
plastic surgery procedures available, and it has been in­
terfaced with well-known VR platforms like Oculus Rift and
zSpace 3D tablet to provide a more immersive experience
for the user.35,36 Besides, a MicroSim VR simulator37 or a
combination of PlayStation VR headset with a digital mi­
croscope38 could be a cost-effective alternative to ex­
pensive traditional training that requires time-consuming
setup to replicate the actual experience of performing mi­
crosurgery. With the advancement of technology, VR
equipment has become more realistic by incorporating
tactile, visual, and acoustic experiences, which is particu­
larly useful in orthognathic maxillofacial surgery that in­
volves bone cutting, drilling, and plate fixation.3,39
MR, also known as the hybrid of VR and AR, works to blur
the lines between the real and digital worlds in an effort to
give users the advantages of both. Adding to the founda­
tions laid by VR's expansive field of view for an immersive
experience and AR's translucent HMD device that allows the
user to remain anchored in the real world, MR enhances the
interaction experience by introducing an additional func­
tion that permits greater manipulation of both virtual and
real-world environments primarily through the use of body
motions and movements.40 Microsoft Hololens, the first
commercially available MR headset, gives trainees a visual
appreciation of actual surgical processes taking place in the
operating theater while simultaneously allowing them to
manipulate digital objects in the platform in a stepwise
manner.36,40 In terms of surgical anatomy education, apart
from its potential as an alternative to cadaveric dissec­
tion,41 Hololens could be a valuable intraoperative naviga­
tion tool owing to its high accuracy in aligning holographic
markings to the patient,42,43 as proven by our clinical ex­
perience (Figure 3). Similar to AR, Hololens has been shown
to be a helpful telemedicine tool,5 and its applicability
could be further broadened to bedside teaching in non­
clinical settings since it allows observation from the first-
person perspective with simultaneous viewing of relevant
clinical information on a single screen.44
However, in this review, we have decided to concentrate
our attention on the application of AR in plastic surgery
 Y.M. Khoong, S. Luo, X. Huang et al.

Figure 3 The Microsoft Hololens mixed reality headset as an accurate intraoperative navigation tool. (A) In the preoperative
stage, software was used to convert computed tomography angiography imaging into a high-quality model optimized for augmented
reality. (B) During intraoperative settings, surgeons wearing HoloLens have access to the same hologram and can alter it with ease
using just hand gestures and vocal commands. The use of holograms permitted precise overlay of patient-specific virtual images
onto the patient's body surface.

education for the following reasons: It has been demon­
strated that VR is more immersive and engaging due to its
wide field of view45; however, AR may be a better option
given that the real world should ideally remain an integral
part of the user's experience during surgical training. Be­
sides, while VR provides a more immersive experience, se­
vere motion sickness is a prevalent side effect that may
limit long-hour use of the device. This makes AR a more
appealing alternative because users often only experience
less severe problems, such as eyestrain, that are typically
ignorable.46 Despite the fact that MR appears to be superior
to AR considering its enhanced capacity to interact with
both real and virtual aspects, its prohibitively high price —
$3500 for Microsoft Hololens 247 — has prevented its wide­
spread application at present.44
Discussion
Throughout surgical training, it is essential that trainees
display competence in technical knowledge and clinical
expertize, problem-solving and judgment under pressure,
commitment to continued professional development, and
effective communication. With these features, AR could be
a game-changer for the future of surgical education in to­
day's technologically advanced era. Anatomical knowledge
and precision in surgical technique are two areas where
plastic surgery training places a strong emphasis. Formerly,
these were accomplished by extensive practice on cadaver
dissections and hands-on experience on actual patients.
With the increased importance of patient safety in this
technologically advanced era, we seek a high-tech solution
that could continue to foster learning in a safe environment
and be of great assistance to trainees by ensuring that they
are always engaged in an interactive learning environment,
whether during surgery or off-duty. With a high-fidelity AR
surgical training platform equipped with essential inter­
active tools, remote supervised operating sessions could be
done with ease, ensuring that every trainee's action is
closely supervised at all times and any mistakes are cor­
rected in a timely manner. This type of communication has
the potential to expedite their learning progress and refine
their surgical skills. With the AR feature that enables trai­
nees to "see through" patients in a clear, three-dimensional,
360-degree perspective, the safety of patients, including
those with anatomical variations or severely distorted
anatomical structures, could be increased by preventing
blind dissection during surgery.
The expense of such cutting-edge technology is un­
questionably of interest to the surgeons. Indeed, they are
not inexpensive, but when compared to the average $2250
cost of manually videotaping, HMDs appear more cost-ef­
fective. The previously stated first-generation Google Glass
has a total price of $1520 and consists of a single-purchase
device plus an optional portable power pack.4 Epson's
Moverio Smart Glasses, another well-known AR device,
range from $579 to $999 depending on the model.48 Al­
though the current cost of these devices may make them
out of reach for most institutions, we remain optimistic that
this will change as technology evolves.
Other problems include its application and whether or
not it would be "distracting" intraoperatively. Currently,
there is a lack of data regarding its user-friendliness and
learning curve; however, based on its positive response in a
systematic review49 that examined the outcome measures
of competency, surgical opinion, and postoperative com­
plication rate despite the increased operative duration in
other surgical specialties,50–53 we believe that once in­
tegrated, like other new technologies, AR would become an
indispensable educational tool. Although AR in plastic sur­
gery is still in its infancy, the outcomes of the aforemen­
tioned applications are encouraging, leading us to predict
that AR will prove to be just as successful in plastic surgery
residencies as it has been in other surgical specialties.
However, routinely incorporating such technology into a
curriculum is not without pitfalls. In identifying anatomical
structures, for instance, trainees may become overly reliant
on such technology and lose the ability to independently
interpret images when AR is unavailable. In addition,

260
 Journal of Plastic, Reconstructive & Aesthetic Surgery 82 (2023) 255–263
surgical video documentation necessitates the transfer of
patients' confidential data, increasing the risk of cyber­
attack. These platforms, which aim to establish health care
equity on a worldwide scale, are dependent, at least for the
time being, on a reliable wireless internet connection,
which can be challenging in low-income countries.7,11 The
present version of Google Glass has significant problems,
including poor image resolution, overexposure, limited
battery life, and the inability to record longer than 10-
second recordings with a voice command,7,10 for which it
may be more suitable for recording a brief glimpse of a
trainee's development than it is for documenting surgical
procedures on video.54 Its current design requires it to be
worn over surgical loupes to achieve the appropriate mag­
nification,7 and it does not permit a proper viewing angle of
the surgical field without the user hyperextending their
neck.4,55 Another issue with existing AR technology is that it
is "too unrealistic," as most of them lack haptic feedback,
which is essential for training plastic surgeons in traction
and tension management.56
Since the beginning of the pandemic, online meeting
platforms such as Zoom, Microsoft Teams, and Google Meet
have been indispensable communication tools for staying
in touch with colleagues. Moving forward, an essential
area of attention for future research would be the ex­
ploration of a technology that enables smooth tele­
mentoring despite a reduced bandwidth, without
compromising video resolution or transmission time. We
anticipate Google's current work on the soon-to-be-re­
leased Glass enterprise edition 2 that will include Google
Meet and improved focusing and precision functionality.57
The possibilities offered by HMDs are vast; yet, these dis­
plays may be made "smarter" by including some of the
fundamental photographic features on our smartphones,
such as autofocus, autoexposure, and zoom control. Fur­
thermore, incorporating an eye-tracker into the wearable
device is a wonderful concept to enable a true first-person
perspective of the surgical field, as illustrated in Hololens
by Lu et al. and Kapp et al.58,59 Although AR devices have
already been put to use in the aforementioned aspects,
they have not yet been put to use in plastic surgery as a
rehearsal surgical simulation tool to guide through the
basic surgical steps, as in specialties like ophthalmology52
and urologic surgery.51 If such a tool were to be developed
in the future, incorporating simulation models with ana­
tomical variance and unfavorable conditions to accurately
replicate the challenges surgeons face in practice would
be vital. Integrating AI into immersive technology could
even potentially expand the usage of immersive gadgets as
a reliable, automated instrument for determining trainees'
strengths and weaknesses. The only way to do all of this,
however, is through a strong multidisciplinary collabora­
tion between surgeons and engineers.
As a narrative review, we sought to highlight significant
studies and summarize the current literature on the use of
AR in plastic surgery education and training. This is not,
however, a comprehensive or systematic review. As there
has been a scarcity of research that focuses on the use of AR
in plastic surgery education compared to other surgical
specialties, we have included papers from these specialties
in an effort to provide light on their future applications in
plastic surgery.
261
Is AR a worthwhile investment for training in plastic
surgery? Perhaps we do not have a definitive answer at this
time, but given the potential of AR in today's technologi­
cally advanced world, we anticipate future comparative
studies that provide more clear evidence of the benefits
that AR would provide to plastic surgery trainees.
Conclusion
The rise of immersive technology has been exponential, but
its potential applications in plastic surgery have only re­
cently begun to be explored. However, as a result of the
pandemic, shorter training hours, and increased emphasis
on patient safety, the way plastic surgery education and
training are delivered has changed dramatically recently.
Since the implementation of immersive technology is con­
sistent with educational goals in plastic surgery, its use has
started to increase to include a wider range of surgical
training scenarios. Although immersive technology will
never be able to fully replace hands-on training, it will still
play a crucial role in bridging the theory–practice gap in this
digital age. We are optimistic that existing shortcomings in
the present AR gadgets will soon be rectified with the
continued research and technical advancements. Let’s an­
ticipate how this new, albeit still emerging, immersive
technology shapes the future generation of plastic surgeons!
Funding
This study was supported by the National Natural Science
Foundation of China (82072177), ‘Two Hundred Talent’
Program, and "Hengjie" Program of Shanghai Health Youth
Talent Reward Foundation.
Ethical approval
Not required.
CRediT authorship contribution statement
Conception and design: YMK, SYL, TZ; collection and as­
sembly of data: YMK, TRJ, HX, HL; data analysis and inter­
pretation: YMK, XH, MXL, YHL; manuscript writing: all
authors; manuscript revision: YMK, XH, SCG; final approval
of the manuscript: all authors.
Declaration of Competing Interest
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
 Y.M. Khoong, S. Luo, X. Huang et al.
References
1. Zhou C, Zhu M, Shi Y, et al. Robot-assisted surgery for man­
dibular angle split osteotomy using augmented reality: pre­
liminary results on clinical animal experiment. Aesthet Plast
Surg 2017;41(5):1228–36. https://doi.org/10.1007/S00266-
017-0900-5.
2. Alpaugh K, Ast MP, Haas SB. Immersive technologies for total
knee arthroplasty surgical education. Arch Orthop Trauma Surg
2021;141(12):2331–5. https://doi.org/10.1007/S00402-021-
04174-7.
3. Wu F, Chen X, Lin Y, et al. A virtual training system for max­
illofacial surgery using advanced haptic feedback and im­
mersive workbench. Int J Med Robot Comput Assist Surg
2014;10(1):78–87. https://doi.org/10.1002/RCS.1514.
4. Davis CR, Rosenfield LK. Looking at plastic surgery through
google glass: part 1. Systematic review of google glass evi­
dence and the first plastic surgical procedures. Plast
Reconstr Surg 2015;135(3):918–28. https://doi.org/10.
1097/PRS.0000000000001056.
5. Mitsuno D, Hirota Y, Akamatsu J, Kino H, Okamoto T, Ueda
K. Telementoring demonstration in craniofacial surgery with
hololens, skype, and three-layer facial models. J Craniofac
Surg 2019;30(1):28–32. https://doi.org/10.1097/SCS.
0000000000004899.
6. 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(3). https://doi.org/10.1097/GOX.0000000000001708.
7. McCullough MC, Kulber L, Sammons P, Santos P, Kulber DA.
Google glass for remote surgical tele-proctoring in low- And
middle-income countries: a feasibility study from Mozambique.
Plast Reconstr Surg Glob Open 2018;6(12). https://doi.org/10.
1097/GOX.0000000000001999.
8. Moro C, Štromberga Z, Raikos A, Stirling A. The effectiveness of
virtual and augmented reality in health sciences and medical
anatomy. Anat Sci Educ 2017;10(6):549–59. https://doi.org/
10.1002/ASE.1696.
9. Wei NJ, Dougherty B, Myers A, Badawy SM. Using Google glass in
surgical settings: systematic review. JMIR Mhealth Uhealth
2018;6(3). https://doi.org/10.2196/MHEALTH.9409.
10. Sinkin JC, Rahman OF, Nahabedian MY. Google glass in the
operating room: the plastic surgeon’s perspective. Plast
Reconstr Surg 2016;138(1):298–302. https://doi.org/10.1097/
PRS.0000000000002307.
11. Vyas RM, Sayadi LR, Bendit D, Hamdan US. Using virtual aug­
mented reality to remotely proctor overseas surgical outreach:
building long-term international capacity and sustainability.
Plast Reconstr Surg 2020;146(5):622E–9E. https://doi.org/10.
1097/PRS.0000000000007293.
12. Mughal M, Din AH, O’Connor EF, Roblin P, Rose V. Breaking
down training barriers: a novel method of delivering plastic
surgery training through augmented reality. J Plast Reconstr
Aesthet Surg 2021;74(5):1101–60. https://doi.org/10.1016/J.
BJPS.2020.10.077.
13. Pereira N, Kufeke M, Parada L, et al. Augmented reality mi­
crosurgical planning with a smartphone (ARM-PS): a dissection
route map in your pocket. J Plast Reconstr Aesthet Surg
2019;72(5):759–62. https://doi.org/10.1016/J.BJPS.2018.12.
023.
14. Nishimoto S, Tonooka M, Fujita K, et al. An augmented reality
system in lymphatico-venous anastomosis surgery. J Surg Case
Rep 2016;5:1–3. https://doi.org/10.1093/jscr/rjw047.
15. Suzuki Y, Kajita H, Watanabe S, et al. Surgical applications of
lymphatic vessel visualization using photoacoustic imaging and
augmented reality. J Clin Med 2022;11(1). https://doi.org/10.
3390/JCM11010194/S1.
262
16. Greenberg JA, Schwarz E, Paige J, Dort J, Bachman S. At-home
hands-on surgical training during COVID19: proof of concept using a
virtual telementoring platform. Surg Endosc 2021;35(5):1963–9.
https://doi.org/10.1007/S00464-021-08470-6.
17. El-Asmar JM, Labban M, El-Hajj A. Integration of aquablation
through telemetry: an alternative to onsite proctoring. World J
Urol 2021;39(9):3473–9. https://doi.org/10.1007/S00345-021-
03603-X.
18. Shalhoub J, Santos C, Bussey M, Eardley I, Allum W. A de­
scriptive analysis of the use of workplace-based assessments in
UK surgical training. J Surg Educ 2015;72(5):786–94. https://
doi.org/10.1016/J.JSURG.2015.03.019.
19. Evans HL, O’Shea DJ, Morris AE, et al. A comparison of Google
Glass and traditional video vantage points for bedside proce­
dural skill assessment. Am J Surg 2016;211(2):336–42. https://
doi.org/10.1016/J.AMJSURG.2015.07.029.
20. Aryal KR, Currow C, Downey S, Praseedom R, Seager A. Work-
based assessments in higher general surgical training program:
a mixed methods study exploring trainers’ and trainees’ views
and experiences. Surg J 2020;6(1):e49. https://doi.org/10.
1055/S-0040-1708062.
21. Karim JS, Hachach-Haram N, Dasgupta P. Bolstering the sur­
gical response to COVID-19: how virtual technology will save
lives and safeguard surgical practice. BJU Int 2020;125(6):E18.
https://doi.org/10.1111/BJU.15080.
22. Molteni G, Nocini R, Ghirelli M, et al. Free flap head and neck
microsurgery with VITOMⓇ 3D: surgical outcomes and surgeon’s
perspective. Auris Nasus Larynx 2021;48(3):464–70. https://
doi.org/10.1016/J.ANL.2020.09.010.
23. Pafitanis G, Hadjiandreou M, Alamri A, Uff C, Walsh D, Myers
S. The Exoscope versus operating microscope in micro­
vascular surgery: a simulation non-inferiority trial. Arch
Plast Surg 2020;47(3):242–9. https://doi.org/10.5999/APS.
2019.01473.
24. Piatkowski AA, Keuter XHA, Schols RM, van der Hulst RRWJ.
Potential of performing a microvascular free flap reconstruc­
tion using solely a 3D exoscope instead of a conventional mi­
croscope. J Plast Reconstr Aesthet Surg 2018;71(11):1664–78.
https://doi.org/10.1016/J.BJPS.2018.07.032.
25. Matsui C, Banda CH, Okada Y, et al. Shaping the future of
microsurgery: combination of exoscope and smart glasses. J
Plast Reconstr Aesthet Surg 2022;75(2):893–939. https://doi.
org/10.1016/J.BJPS.2021.11.009.
26. Lin L, Shi Y, Tan A, et al. Mandibular angle split osteotomy
based on a novel augmented reality navigation using specia­
lized robot-assisted arms - a feasibility study. J Cranio-
Maxillofac Surg 2016;44(2):215–23. https://doi.org/10.1016/
J.JCMS.2015.10.024.
27. Moorthy K, Munz Y, Dosis A, et al. Dexterity enhancement with
robotic surgery. Surg Endosc Other Interv Tech 2004;18(5):790–5.
https://doi.org/10.1007/S00464-003-8922-2.
28. van Mulken TJM, Wolfs JAGN, Qiu SS, et al. One-year outcomes
of the first human trial on robot-assisted lymphaticovenous
anastomosis for breast cancer–related lymphedema. Plast
Reconstr Surg 2022;149(1):151–61. https://doi.org/10.1097/
PRS.0000000000008670.
29. Shi Y, Lin L, Zhou C, Zhu M, Xie L, Chai G. A study of an assisting
robot for mandible plastic surgery based on augmented reality.
Minim Invasive Ther Allied Technol 2017;26(1):23–30. https://
doi.org/10.1080/13645706.2016.1216864.
30. van Mulken TJM, Schols RM, Scharmga AMJ, et al. First-in-
human robotic supermicrosurgery using a dedicated micro­
surgical robot for treating breast cancer-related lymphedema:
a randomized pilot trial. Nat Commun 2020;11(1). https://doi.
org/10.1038/S41467-019-14188-W.
31. Izard SG, Juanes JA, García Peñalvo FJ, Estella JMG, Ledesma
MJS, Ruisoto P. Virtual reality as an educational and training
 Journal of Plastic, Reconstructive & Aesthetic Surgery 82 (2023) 255–263
tool for medicine. J Med Syst 2018;42(3). https://doi.org/10.
1007/S10916-018-0900-2.
32. Tulipan J, Miller A, Park AG, Labrum JT, Ilyas AM. Touch sur­
gery: analysis and assessment of validity of a hand surgery si­
mulation “App”. Hand 2019;14(3):311–6. https://doi.org/10.
1177/1558944717751192.
33. Bunogerane GJ, Taylor K, Lin Y, Costas-Chavarri A. Using touch
surgery to improve surgical education in low- and middle-in­
come settings: a randomized control trial. J Surg Educ
2018;75(1):231–7. https://doi.org/10.1016/J.JSURG.2017.06.
016.
34. Sugand K, Mawkin M, Gupte C. Validating Touch Surgery™: a
cognitive task simulation and rehearsal app for intramedullary
femoral nailing. Injury 2015;46(11):2212–6. https://doi.org/
10.1016/J.INJURY.2015.05.013.
35. Touch surgery – can this app help train surgeons? BBC News.
〈https://www.bbc.com/news/av/technology-32844630〉
[Accessed 8 April 2022].
36. Lee GK, Moshrefi S, Fuertes V, Veeravagu L, Nazerali R, Lin SJ.
What is your reality? Virtual, augmented, and mixed reality in
plastic surgery training, education, and practice. Plast
Reconstr Surg 2021;147(2):505–11. https://doi.org/10.1097/
PRS.0000000000007595.
37. Hüsken N, Schuppe O, Sismanidis E, Beier F. MicroSim - a micro­
surgical training simulator. Stud Health Technol Inf
2013;184:205–9. https://doi.org/10.3233/978-1-61499-209-7-205.
38. Huang TCT, Sabbagh MD, Adabi K, et al. Compact and eco­
nomical microsurgical training made possible with virtual rea­
lity. Plast Reconstr Surg 2018;142(6):993E–5E. https://doi.
org/10.1097/PRS.0000000000005059.
39. Lin Y, Wang X, Wu F, Chen X, Wang C, Shen G. Development and
validation of a surgical training simulator with haptic feedback
for learning bone-sawing skill. J Biomed Inf 2014;48:122–9.
https://doi.org/10.1016/J.JBI.2013.12.010.
40. Tepper OM, Rudy HL, Lefkowitz A, et al. Mixed reality with
HoloLens: where virtual reality meets augmented reality in the
operating room. Plast Reconstr Surg 2017;140(5):1066–70.
https://doi.org/10.1097/PRS.0000000000003802.
41. Kumar N, Pandey S, Rahman E. A novel three-dimensional in­
teractive virtual face to facilitate facial anatomy teaching
using Microsoft HoloLens. Aesthet Plast Surg
2021;45(3):1005–11. https://doi.org/10.1007/S00266-020-
02110-5.
42. Rudy HL, Schreiber JS, Wake N, et al. Intraoperative navigation
in plastic surgery with augmented reality: a preclinical vali­
dation study. Plast Reconstr Surg 2022;149(3):573e–80e.
https://doi.org/10.1097/PRS.0000000000008875.
43. Wesselius TS, Meulstee JW, Luijten G, Xi T, Maal TJJ, Ulrich
DJO. Holographic augmented reality for DIEP flap harvest.
Plast Reconstr Surg 2021;147(1):25e–9e. https://doi.org/10.
1097/PRS.0000000000007457.
44. Mill T, Parikh S, Allen A, et al. Live streaming ward rounds using
wearable technology to teach medical students: a pilot study.
BMJ Simul Technol Enhanc Learn 2021;0:1–7. https://doi.org/
10.1136/bmjstel-2021-000864.
45. Huang KT, Ball C, Francis J, Ratan R, Boumis J, Fordham J.
Augmented versus virtual reality in education: an exploratory
263
study examining science knowledge retention when using
augmented reality/virtual reality mobile applications. Cyber
Behav Soc Netw 2019;22(2):105–10. https://doi.org/10.1089/
CYBER.2018.0150.
46. Hughes CL, Fidopiastis C, Stanney KM, Bailey PS, Ruiz E. The
psychometrics of cybersickness in augmented reality. Front
Virtual Real 2020;1:34. https://doi.org/10.3389/FRVIR.2020.
602954/BIBTEX.
47. HoloLens 2—pricing and options. Microsoft HoloLens. 〈https://
www.microsoft.com/en-us/hololens/buy〉 [Accessed 25
September 2022].
48. Smart glasses. Augmented reality headsets. Epson.com. Epson
US. 〈https://epson.com/moverio-smart-glasses-augmented-
reality-devices-headsets〉 [Accessed 19 September 2022].
49. Williams MA, McVeigh J, Handa AI, Lee R. Augmented reality in
surgical training: a systematic review. Post Med J
2020;96(1139):537–42. https://doi.org/10.1136/POSTGRADMEDJ-
2020-137600.
50. Alzouebi IA, Saad S, Farmer T, Green S. Is the use of augmented
reality-assisted surgery beneficial in urological education? A
systematic review. Curr Urol 2021;15(3):148–52. https://doi.
org/10.1097/CU9.0000000000000036.
51. Dickey RM, Srikishen N, Lipshultz LI, Spiess PE, Carrion RE,
Hakky TS. Augmented reality assisted surgery: a urologic
training tool. Asian J Androl 2016;18(5):732. https://doi.org/
10.4103/1008-682X.166436.
52. Lowater SJ, Grauslund J, Vergmann AS. Modern educational
simulation-based tools among residents of ophthalmology: a
narrative review. Ophthalmol Ther 2022;11(6):1961–74.
https://doi.org/10.1007/S40123-022-00559-Y.
53. Paro MR, Hersh DS, Bulsara KR. History of virtual reality and
augmented reality in neurosurgical training. World Neurosurg
2022;167:37–43. https://doi.org/10.1016/J.WNEU.2022.08.
042.
54. Paro JAM, Nazareli R, Gurjala A, Berger A, Lee GK. Video-based
self-review comparing: Google glass and GoPro technologies.
Ann Plast Surg 2015;74:S71–4. https://doi.org/10.1097/SAP.
0000000000000423.
55. Hashimoto DA, Phitayakorn R, Fernandez-del Castillo C,
Meireles O. A blinded assessment of video quality in wearable
technology for telementoring in open surgery: the Google Glass
experience. Surg Endosc 2016;30(1):372–8. https://doi.org/
10.1007/S00464-015-4178-X.
56. Hangai S, Nozaki T, Soma T, et al. Development of a micro­
surgery-assisted robot for high-precision thread traction and
tension control, and confirmation of its applicability. Int J Med
Robot Comput Assist Surg 2021;17(2). https://doi.org/10.
1002/RCS.2205.
57. Glass – Glass. 〈https://www.google.com/glass/start/〉
[Accessed 19 September 2022].
58. Lu S, Sanchez Perdomo YP, Jiang X, Zheng B. Integrating eye-
tracking to augmented reality system for surgical training. J
Med Syst 2020;44(11). https://doi.org/10.1007/S10916-020-
01656-W.
59. Kapp S, Barz M, Mukhametov S, Sonntag D, Kuhn J. Arett: aug­
mented reality eye tracking toolkit for head mounted displays.
Sensors 2021;21(6). https://doi.org/10.3390/S21062234.