Download PDF
J Reconstr Microsurg 2015; 31(09): 636-642
DOI: 10.1055/s-0035-1556053
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Loupes-Only Microsurgery is a Safe Alternative to the Operating Microscope: An Analysis of 1,649 Consecutive Free Flap Breast Reconstructions

Christopher J. Pannucci
1   Division of Plastic Surgery, University of Utah, Salt Lake City, Utah
,
Marten N. Basta
2   Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Stephen J. Kovach
2   Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Suhail K. Kanchwala
2   Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Liza C. Wu
2   Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Joseph M. Serletti
2   Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
› Author Affiliations
Further Information

Publication History

29 January 2015

10 May 2015

Publication Date:
10 July 2015 (online)

    Permissions and Reprints

Abstract

Background Loupes-only microsurgery challenges the paradigm that free flap surgery requires an operating microscope. We describe our loupes-only microsurgery experience with an emphasis on rates of intraoperative anastomotic revision and total flap loss.

Methods We identified all patients having breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric perforator (DIEP) flaps over 7 years. We examined rates of intraoperative anastomotic revision and total flap loss as markers of technical quality. For one high-volume surgeon who started loupes-only microsurgery while at our institution, we examined rates of intraoperative anastomotic revision and total flap loss rates over time to evaluate for a learning curve.

Results We performed 1,649 ms-TRAM or DIEP flaps in 1,063 patients. For 1,649 flaps, the rate of artery anastomotic revision was 2.2% (36 arteries) and venous anastomotic revision was 2.2% (37 veins). Any microvascular revision was performed in 3.5% (58 flaps). Total flap loss rate was 1.2% (20 flaps).

For the “learning curve” analysis, there were no clinically relevant differences in rates of any intraoperative anastomotic revision or total flap loss during the first 60 months after loupes-only microsurgery was adopted. Total flap loss during this surgeon's first 60 months of loupes-only microsurgery was 1.6% (10 of 638 flaps).

Conclusions Loupes-only microsurgery is a safe alternative to the operating microscope for free flap breast reconstruction using the deep inferior epigastric system. Our total flap loss rate of 1.2% in 1,649 flaps is at the low end of published flap loss rates.

Keywords

loupes - microscope - free flap - breast reconstruction - TRAM - DIEP
 

  • References

  • 1 McLean DH, Buncke Jr HJ. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 1972; 49 (3) 268-274
    CrossrefPubMedGoogle Scholar
  • 2 Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009; 31 (1) 45-51
    CrossrefPubMedGoogle Scholar
  • 3 Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130 (3) 579-589
    CrossrefPubMedGoogle Scholar
  • 4 Saint-Cyr M, Youssef A, Bae HW, Robb GL, Chang DW. Changing trends in recipient vessel selection for microvascular autologous breast reconstruction: an analysis of 1483 consecutive cases. Plast Reconstr Surg 2007; 119 (7) 1993-2000
    CrossrefPubMedGoogle Scholar
  • 5 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (7) 2092-2100
    CrossrefPubMedGoogle Scholar
  • 6 Vijan SS, Tran VN. Microvascular breast reconstruction pedicle thrombosis: how long can we wait?. Microsurgery 2007; 27 (6) 544-547
    CrossrefPubMedGoogle Scholar
  • 7 Vega S, Smartt Jr JM, Jiang S , et al. 500 Consecutive patients with free TRAM flap breast reconstruction: a single surgeon's experience. Plast Reconstr Surg 2008; 122 (2) 329-339
    CrossrefPubMedGoogle Scholar
  • 8 Tomaino MM. Routine use of loupe magnification for microvascular anastomoses: at what price?. Plast Reconstr Surg 1996; 97 (1) 248-249
    CrossrefPubMedGoogle Scholar
  • 9 Serletti JM, Deuber MA, Guidera PM , et al. Comparison of the operating microscope and loupes for free microvascular tissue transfer. Plast Reconstr Surg 1995; 95 (2) 270-276
    CrossrefPubMedGoogle Scholar
  • 10 Shenaq SM, Klebuc MJ, Vargo D. Free-tissue transfer with the aid of loupe magnification: experience with 251 procedures. Plast Reconstr Surg 1995; 95 (2) 261-269
    CrossrefPubMedGoogle Scholar
  • 11 Ashworth DR, Whear NM, Fan V. Radial free flaps using loupe magnification: audit of 97 cases of orofacial reconstruction. Br J Oral Maxillofac Surg 2004; 42 (1) 36-37
    CrossrefPubMedGoogle Scholar
  • 12 Ross DA, Ariyan S, Restifo R, Sasaki CT. Use of the operating microscope and loupes for head and neck free microvascular tissue transfer: a retrospective comparison. Arch Otolaryngol Head Neck Surg 2003; 129 (2) 189-193
    CrossrefPubMedGoogle Scholar
  • 13 Pieptu D, Luchian S. Loupes-only microsurgery. Microsurgery 2003; 23 (3) 181-188
    CrossrefPubMedGoogle Scholar
  • 14 Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004; 114 (5) 1077-1083 , discussion 1084–1085
    PubMedGoogle Scholar
  • 15 Menn Z, Spigel A. The superficial inferior epigastric artery (SIEA) flap and its applications in breast reconstruction. In: Salgarello M, , ed. Breast Reconstruction–Current Techniques. Rijeka, Croatia: InTech Europe; 2012. . Available at: http://www.intechopen.com/books/breastreconstruction-current-techniques/the-siea-flap-and-its-applications-in-breast-reconstruction . Accessed December 1, 2014
    CrossrefGoogle Scholar
  • 16 Healy C, Allen Sr RJ. The evolution of perforator flap breast reconstruction: twenty years after the first DIEP flap. J Reconstr Microsurg 2014; 30 (2) 121-125
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (2) 377-381
    CrossrefPubMedGoogle Scholar
  • 18 Clinical and Translational Science Awards (CTSA). REDCap. Available at: www.project-redcap.org . Accessed December 1, 2014
    PubMedGoogle Scholar
  • 19 Cemal Y, Albornoz CR, Disa JJ , et al. A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg 2013; 131 (3) 320e-326e
    CrossrefPubMedGoogle Scholar
  • 20 Askari M, Fisher C, Weniger FG, Bidic S, Lee WP. Anticoagulation therapy in microsurgery: a review. J Hand Surg Am 2006; 31 (5) 836-846
    CrossrefPubMedGoogle Scholar
  • 21 Lighthall JG, Cain R, Ghanem TA, Wax MK. Effect of postoperative aspirin on outcomes in microvascular free tissue transfer surgery. Otolaryngol Head Neck Surg 2013; 148 (1) 40-46
    CrossrefPubMedGoogle Scholar
  • 22 Froemel D, Fitzsimons SJ, Frank J, Sauerbier M, Meurer A, Barker JH. A review of thrombosis and antithrombotic therapy in microvascular surgery. Eur Surg Res 2013; 50 (1) 32-43
    CrossrefPubMedGoogle Scholar
  • 23 Stanbury SJ, Elfar J. The use of surgical loupes in microsurgery. J Hand Surg Am 2011; 36 (1) 154-156
    PubMedGoogle Scholar
  • 24 Capone AC, Parikh PM, Gatti ME, Davidson BJ, Davison SP. Occupational injury in plastic surgeons. Plast Reconstr Surg 2010; 125 (5) 1555-1561
    CrossrefPubMedGoogle Scholar
  • 25 Rohrich RJ. Why i hate the headlight. and other ways to protect your cervical spine. Plast Reconstr Surg 2001; 107 (4) 1037-1038
    CrossrefPubMedGoogle Scholar
  • 26 Tzeng YS, Chen SG, Chen TM. Herniation of the cervical disk in plastic surgeons. Ann Plast Surg 2012; 69 (6) 672-674
    CrossrefPubMedGoogle Scholar
  • 27 Baker JM, Meals RA. A practical guide to surgical loupes. J Hand Surg Am 1997; 22 (6) 967-974
    CrossrefPubMedGoogle Scholar
  • 28 Davidson BJ, Guardiani E, Wang A. Adopting the operating microscope in thyroid surgery: safety, efficiency, and ergonomics. Head Neck 2010; 32 (2) 154-159
    PubMedGoogle Scholar
  • 29 Andrades P, Benítez S, Danilla S, Erazo C, Hasbun A, Fix J. Vascular diameter determining the magnification for a microvascular anastomosis. J Reconstr Microsurg 2008; 24 (3) 177-181
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Schoeffl H, Lazzeri D, Schnelzer R, Froschauer SM, Huemer GM. Optical magnification should be mandatory for microsurgery: scientific basis and clinical data contributing to quality assurance. Arch Plast Surg 2013; 40 (2) 104-108
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Gorman PJ, Mackay DR, Kutz RH, Banducci DR, Haluck RS. Video microsurgery: evaluation of standard laparoscopic equipment for the practice of microsurgery. Plast Reconstr Surg 2001; 108 (4) 864-869
    CrossrefPubMedGoogle Scholar
  • 32 Replantation surgery surgery in China. Report of the American Replantation Mission to China. Plast Reconstr Surg 1973; 52 (5) 476-489
    CrossrefPubMedGoogle Scholar
  • 33 Hallock GG. Macrovascular surgery and the microsurgeon. J Reconstr Microsurg 1997; 13 (8) 563-570
    Article in Thieme ConnectPubMedGoogle Scholar