BACKGROUND: Dissecting free tissue flaps can be challenging and time-consuming. Imaging technologies are typically used to assist with preoperative planning. However, conventional methods have limitations that could potentially be overcome by extended reality technologies. This systematic review aimed to evaluate the current use of extended reality (XR) in preoperative planning for microsurgical free flaps and assess its effectiveness as a tool in this context. METHODS: The systematic review was conducted following the preferred reporting items of systematic reviews and meta-analyses guidelines. Articles identified through the PubMed, Ovid, Web of Science, and Scopus databases were screened based on titles and abstracts, and relevant articles were assessed in full text. Inclusion criteria were: use of XR for vascular visualization in plastic and reconstructive surgery, reported workflow, accuracy, operative times, the surgeon's opinion, or complications. Exclusion criteria were: unavailability of full text, non-English, non-human, or other review articles. Quality assessment was performed using center for evidence-based medicine level of evidence and Joanna Briggs Institute critical appraisal tools. RESULTS: Overall, 7 articles on virtual reality and 26 articles on augmented reality in plastic and reconstructive surgical procedures were identified. Virtual reality demonstrated better visualization of patient-specific anatomy and was more time efficient than CT angiography. Augmented reality was found to be more accurate and time efficient than Doppler ultrasound. However, successful XR implementation necessitates a well-designed workflow. The results are limited by the designs of the included studies and level of evidence they represent. CONCLUSION: XR technologies show promise in preoperative planning of microsurgical free flaps. Standardized outcome measurements and prospective, comparative studies are essential for a comprehensive understanding of the clinical value of XR-based preoperative planning.