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
