The 3-dimensional (3D) head-up display (HUD) exoscope is a novel magnification system providing stereoscopic, high-definition visualization without conventional microscope eyepieces that offers potential ergonomic and workflow advantages for microsurgeons. The authors compared the feasibility and outcomes of microsurgical breast reconstruction performed using the 3D HUD exoscope versus a conventional surgical microscope. A retrospective review was conducted of 34 patients (37 flaps) who underwent free flap breast reconstruction between July and September of 2024. Eighteen patients (21 flaps) were treated using the 3D HUD exoscope, and 16 patients (16 flaps) with a conventional microscope. Demographics, operative measures, and outcomes were analyzed. The mean microanastomosis time was similar between the 3D HUD exoscope and microscope groups (28.0 ± 4.1 versus 26.5 ± 11.7 minutes; P = 0.60). All flaps survived with no total flap loss. Venous congestion requiring intervention occurred in 1 flap in the 3D HUD group (4.8%), with no significant difference in revisional surgery rates. The 3D HUD exoscope accommodated both hand-sewn and coupler techniques, enhanced ergonomic positioning, and mitigated operator strain by eliminating the requirement for rigid eyepiece alignment. Its compact, mobile configuration facilitated more efficient setup compared with conventional microscopes. With surgical performance comparable to that of the traditional microscope, the HUD system provides notable advantages in surgeon comfort and team visualization. These findings support its role as a viable alternative for microsurgical breast reconstruction, with potential applicability in supermicrosurgery, telemicrosurgery, and robotic-assisted procedures.