# State-of-the-Art Medical Imaging Supporting Supermicrosurgery: A Scoping Review, Practical Guidelines, and Illustrative Case Report

## TL;DR

This paper reviews advanced imaging techniques used in supermicrosurgery to improve surgical precision and outcomes.

## Contribution

The paper provides practical guidelines and compares state-of-the-art imaging modalities for supermicrosurgery.

## Key findings

- UHFUS is a key tool for preoperative planning in flap and lymphatic surgery.
- Near-infrared fluorescent lymphography and indocyanine green angiography are essential in modern flap surgery.
- Contrast-enhanced magnetic resonance lymphography offers high-resolution imaging of lymphatic vessels.

## Abstract

In the era of supermicrosurgery, clinicians need more precise imaging modalities to know the exact microvascular and lymphatic anatomy of the patient. The goal of this review is to answer the research question “What are the state-of-the-art medical imaging modalities supporting supermicrosurgery?”

This study is a scoping review and case report.

Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are well-known current standard imaging modalities in flap surgery. In lymphatic surgery, lymphoscintigraphy is the gold standard. (Ultra)high-frequency ultrasound (UHFUS) has taken a major role in preoperative planning of flap surgery and lymphatic surgery. Practical guidelines on the use of UHFUS in flap planning and lymphatic surgery are described in this review article. Indocyanine green angiography and near-infrared fluorescent lymphography have also become key elements in modern flap surgery and lymphatic surgery. Moreover, contrast-enhanced magnetic resonance lymphography produces high-resolution imaging of superficial as well as deep lymphatic vessels. Laser tomography and photoacoustic imaging are promising experimental imaging techniques in lymphatic surgery.

This review article describes and compares possible imaging modalities for preoperative planning and intraoperative guidance with the aims of enhancing surgical outcomes, reducing operative time, and preventing complications in supermicrosurgery. Moreover, a case report is described in order to illustrate the practical imaging work-up in daily practice.