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Background: Superficial temporal artery (STA)-middle cerebral artery (MCA) side-to-side microvascular anastomosis can achieve the same clinical effects as traditional STA-MCA end-to-side anastomosis in extracranial-intracranial revascularization surgery, furthermore, STA-MCA side-to-side anastomosis has the lower risk of postoperative cerebral hyperperfusion syndrome (CHS) and the potential to recruit all scalp arteries as the donor sources via self-regulation. Therefore, STA-MCA side-to-side microvascular anastomosis seems to be a revascularization strategy superior to traditional STA-MCA end-to-side anastomosis. In this study, we presented seven cases in which a STA-MCA side-to-side microvascular anastomosis was performed with a 4–5 mm long arteriotomy using the in-situ intraluminal suturing technique. Methods: Superficial temporal artery (STA)-middle cerebral artery (MCA) side-to-side anastomosis was performed in seven patients using the in-situ intraluminal suturing technique. Results: The diameters of the recipient MCA and the donor STA were approximately 0.94 mm (range 0.8–1.4 mm) and 1.65 mm (range 1.4–2.0 mm), respectively, and the length of the arteriotomy was approximately 4.71 mm (range 4–5 mm). The MCA was temporarily occluded in approximately 25.00 min (range 20–29 min). 100% patency rates of the STA-MCA microvascular anastomosis were achieved in all patients. No obvious CHS was recorded. Intraoperative Indocyanine green videoangiography (ICG-VA) and postoperative digital subtraction angiography (DSA) demonstrated three different blood flow distribution patterns after the STA-MCA side-to-side anastomosis, the donor MCA received not only antegrade blood flow from the proximal preanastomotic STA but also retrograde blood flow from the distal postanastomotic STA in one case; the donor MCA received all the antegrade blood from the proximal STA without retrograde blood flow from the distal STA in two case; whereas, the recipient MCA territories received only partial antegrade blood flow from the proximal preanastomotic STA. Conclusions: STA-MCA side-to-side microvascular anastomosis with a 4–5 mm long arteriotomy using the in situ intraluminal suturing technique is a safe and effective revascularization surgery, and the anastomosis can serve as a shunt for blood flow self-regulation. [ABSTRACT FROM AUTHOR]