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Remaining limitations such as short pedicle length and thickness are addressed through perforator-to-perforator supermicrosurgery with submillimeter anastomoses. Progress in high-magnification microscopy, ultra-fine sutures, robotic platforms, and digital exoscopes, alongside AI and augmented reality, points toward safer, more efficient, customized functional and aesthetic 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technical challenges?",{"text":72,"@type":64},"Perforator-to-perforator supermicrosurgery enables anastomosis of submillimeter vessels, helping overcome issues such as short pedicle length and flap thickness with minimal disruption.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},434412,1790929494,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,120,123,127],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & 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[homepage:](homepage: www.elsevier.com/locate/jpra)[ www.elsevier.com/locate/jpra](homepage: www.elsevier.com/locate/jpra)  \nReview Article  \nThe evolution of perforator flaps and the future of microsurgery  \nJoon Pio Hong a,∗, Jin Geun Kwon a, Hyunsuk Peter Suha, Changsik John Paka, Hyung Bae Kim a, Hyun Ho Hana, Hyungjoo Nohb, Jae Young Hurc, Erin Brown d  \na Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul, Korea b Department of Plastic and Reconstructive Surgery, Yas Clinic Khalifa City, Abu Dhabi, United Arab Emirates c Plastic Surgery, Young Young Plastic Surgery Clinic, Seoul, Korea  \nd Department of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, Canada  \na r t i c l e i n f o  \nArticle history:  \nReceived 10 September 2025  \nAccepted 11 September 2025  \nAvailable online 14 September 2025  \nKeywords: Microsurgery Supermicrosurgery Perforator flap Digital microscope  \nRobotic microsurgery platform  \n∗ Corresponding author.  \na b s t r a c t  \nPerforator flaps have transformed reconstructive microsurgery by enabling tissue-specific reconstruction while preserving muscle, fascia, and nerves, minimizing donor site morbidity. Modern techniques—including superthin, ultrathin, and pure skin flaps—enhance flap precision, safety, and versatility. Imaging tools such as CT angiography and high-resolution ultrasound allow accurate mapping of perforator anatomy, improving flap design and outcomes. Challenges like short pedicle length and flap thickness are addressed through perforator-to-perforator supermicrosurgery, enabling anastomosis of submillimeter vessels with minimal disruption. Advances in high-magnification microscopes, ultrafine microsutures, robotic platforms, and digital exoscopes further expand surgical capabilities, improve ergonomics, and shorten the learning curve. Looking ahead, artificial intelligence and augmented reality promise to automate microsurgical tasks, enhance visualization, and optimize functional and aesthetic results. Collectively, these innovations are pushing reconstructive microsurgery toward the  \nE-mail address: [joonphong@amc.seoul.kr](joonphong@amc.seoul.kr) (J.P. Hong).  \n[https://doi.org/10.1016/j.jpra.2025.09.016](https://doi.org/10.1016/j.jpra.2025.09.016)  \n2352-5878/© 2025 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license  \n([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/))  \nJ.P. Hong, J.G. Kwon, H.P. Suh et al. JPRAS Open 47 (2025) 33–42  \n“reconstructive elevator” ideal, achieving safer, more efficient, and highly customized outcomes for patients.  \n© 2025 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. This is an open access article under the CC BY-NC-ND license ([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/))  \nIntroduction of perforator flaps  \nIn the era of the reconstructive elevator concept, achieving both functional and aesthetic surgical outcomes with maximal efficiency has become the standard (Figure 1).1 However, the development of this approach was gradual. In the early days of reconstructive surgery, the primary focus was on wound closure, often without detailed understanding of flap vascularity. The importance of vascular knowledge became evident, as random-pattern flaps with unpredictable blood supply were limited in their ability to cover larger defects. The introduction of axial-pattern flaps, with defined blood supply to muscle and musculocutaneous tissue, provided a framework for flap design. Nevertheless, these flaps often required sacrificing muscle, resulting in functional donor site morbidity and","cbCairoha5QoCA2W","https://ap.wps.com/l/cbCairoha5QoCA2W","pdf",1815260,"English","# Introduction of perforator flaps\n# Additional advantages of perforator flaps\n# Future directions in microsurgery","[{\"question\":\"What makes perforator flaps important in reconstructive microsurgery?\",\"answer\":\"Perforator flaps allow tissue-specific reconstruction while preserving muscle, fascia, and nerves, minimizing donor-site morbidity and supporting safer, more customized outcomes.\"},{\"question\":\"Which imaging methods are highlighted for perforator flap planning?\",\"answer\":\"CT angiography and high-resolution ultrasound are presented as tools for mapping perforator anatomy to improve flap design and results.\"},{\"question\":\"How do supermicrosurgery techniques help address key technical challenges?\",\"answer\":\"Perforator-to-perforator supermicrosurgery enables anastomosis of submillimeter vessels, helping overcome issues such as short pedicle length and flap thickness with minimal disruption.\"}]","The evolution of perforator flaps and the future of microsurgery | PDF",1790669130,25]