From Microscope to Metaverse: Reimagining Supermicrosurgery Training in the Age of <scp>AI</scp> and <scp>AR</scp>

The coming decade will redefine how supermicrosurgeons are prepared for practice. Recent systematic review now demonstrates that simulation-based microsurgical training yields measurable improvements in performance metrics, including time to completion, error rate, and motion efficiency, supporting its role as an evidence-based educational strategy (Savage et al. 2025). Simulation, once supplementary, is now recognized as essential to skill acquisition, bridging theoretical understanding with operative performance (Lin et al. 2025). The future of training will rely not only on microscopes, but also on an integrated digital ecosystem encompassing artificial intelligence, augmented reality, and haptic technologies (Raquepo et al. 2025; Gani et al. 2022). Supermicrosurgery requires meticulous skill to repair vessels and lymphatics less than half a millimeter in diameter, needing repeated practice over extended periods (Kania et al. 2020). Shrinking working hours and increasing subspecialization have reduced opportunities for rehearsal. Competency should be built outside the operating theater. Evidence supports structured simulation curricula, using validated assessment tools such as Structured Assessment of Microsurgery skills (SAMS) and the objective Structured Assessment of Technical Skills (OSATS), enabling trainees to achieve skill benchmarks through stepwise progression (Kania et al. 2020). Animal models, especially rats, were once indispensable for learning vessel techniques. They offered realism but came with ethical, financial, and regulatory burdens. Comparative studies have shown that the transition to non-living alternatives, including cadaveric tissues and sophisticated synthetic constructs, can provide equivalent technical benefit without ethical compromise (Gani et al. 2022). These options are reproducible, accessible, and free from the moral concerns of sentient models. The profession is steadily adopting simulators that provide both fidelity and ethical acceptability, aligning training with broader societal expectations (Ismail and Rahimi 2025). Simulation platforms have advanced rapidly, combining augmented reality to overlay digital information on the surgeon's field, enabling trainees to superimpose vascular maps, instrument paths, and performance metrics while practising within a realistic three-dimensional environment with integrated assessment (Ismail and Rahimi 2025). Visual immersion alone, however, does not ensure skill transfer. The sense of touch remains critical. Randomized trials comparing haptic with non-haptic systems have demonstrated that tactile feedback improves technical performance, particularly when fine control of force and suture handling is required (Gani et al. 2022; Kania et al. 2020). Reproducing tissue resistance and vessel fragility may be the key to successful translation from simulator to clinical practice (Savage et al. 2025). Looking ahead, the concept of a surgical metaverse is becoming tangible. This vision integrates artificial intelligence, augmented reality, and haptic simulation into a unified training environment. Artificial intelligence can analyze movements in real-time, measure tremor and efficiency, and provide structured feedback that is often beyond what a mentor can deliver in the operating room (Savage et al. 2025; Lin et al. 2025; Raquepo et al. 2025). AI-assisted skill assessment has now been validated across multiple microsurgical platforms, with machine-learning models accurately distinguishing novice from expert performance and generating objective feedback that often surpasses traditional checklists. Reviews already outlined applications ranging from objective skill assessment to intraoperative support. A global digital environment would allow trainees to practice within standardized conditions, monitored by objective metrics, and progress based on demonstrated competence rather than variable opportunity (Savage et al. 2025). The microscope revolutionized reconstructive surgery in the last century. In this one, the metaverse may transform how we train. By adopting artificial intelligence, augmented and virtual reality, and haptic realism, the specialty can overcome shrinking training time and the decline of animal laboratories. This vision is not speculative, but an evolution already underway, supported by a growing body of validation studies and multi-center adoption (Kiew et al. 2025). Most importantly, it can prepare future supermicrosurgeons to perform the most delicate operations with confidence from the moment they finish training. For this transformation to succeed, the plastic surgery community must not simply follow the digital evolution but lead it. Conceptualization: Ishith Seth and Warren M. Rozen. Writing – original draft preparation: Ishith Seth and Akshay Soni. Writing – review and editing: All authors. Visualization: Yi Mon and Omar Shadid. Supervision: Warren M. Rozen. Project administration: Akshay Soni, Yi Mon, and Omar Shadid. Authors confirm that all sources of information, data, and ideas are properly cited and that the work of others is appropriately acknowledged. The authors have nothing to report. The authors declare that this viewpoint article is their original work, and no part has been plagiarized. The authors declare no conflicts of interest. The authors confirm that the data supporting the findings of this study are available within the article.