Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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Loupes-Only Microsurgery is a Safe Alternative to the Operating Microscope: An Analysis of 1,649 Consecutive Free Flap Breast Reconstructions
Christopher J. Pannucci, MD MS1, Marten N. Basta, BA2, Stephen J. Kovach, MD2, Suhail K. Kanchwala, MD2, Liza C. Wu, MD2, Joseph M. Serletti, MD2.
1University of Utah, Salt Lake City, UT, USA, 2University of Pennsylvania, Philadelphia, PA, USA.

Purpose:
Microsurgical anastomoses can be performed under the operating microscope with high success rates. High-volume centers have published contemporary flap loss rates of 1.1% to 3.0%. Loupes-only microsurgery challenges the paradigm that free flap surgery requires an operating microscope, and allows microsurgical reconstruction to be performed in community hospitals where an operating microscope would be cost prohibitive. Small series have suggested that loupes-only microsurgery has similar outcomes to microsurgery performed with an operating microscope. Here, we describe our institution’s experience with high-volume loupes-only microsurgery, with an emphasis on intra-operative revision rates and total flap loss rates.
Methods:
We queried our prospectively maintained institutional database for all patients having breast reconstruction with ms-TRAM or DIEP flaps between 2005 and 2012. We did not include patients with SIEA flaps as the vessels are small and the microscope is occasionally used. We examined rates of intra-operative revision of arterial and venous anastomosis and rates of total flap loss as markers of technical quality. For two surgeons who started loupes-only microsurgery while at our institution, we examined a three year flap loss trend to evaluate for a learning curve.
Results:
We identified 1,649 consecutive ms-TRAM or DIEP flaps performed in 1,063 patients at our institution over a seven year period. Patient demographics and comorbid conditions were similar to previously published series. For 1,649 flaps, the rate of anastomotic revision for the artery was 2.2% (36 flaps) and the vein was 2.2% (37 flaps). Any microvascular revision was performed in 3.5% (58 flaps). The ipsilateral side was not significantly more likely to be revised than the contralateral side (3.9% vs. 2.9%, p=0.31). Flap loss rates between the ipsilateral and contralateral side were not significantly different (1.2% vs. 1.2%, p=0.96). Total flap loss rate was 1.2% (20 flaps).
Two attendings began loupes-only microsurgery after starting at our institution. Among 273 flaps done in years one through three after transitioning to loupes-only microsurgery, there was no significant difference in loss rate between years 1 and 2 (1.6% vs. 1.0%, p=0.62) or years 1 and 3 (1.6% vs. 0.9%, p=0.59).
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 acceptable, published flap loss rates. There is no substantial learning curve with this technique. Further research should focus on financial ramifications of loupes-only microsurgery, including extension of practice to the community setting and alteration in total operative time. The ergonomics of loupes-only microsurgery also merits investigation.


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