Loupes for Magnification: One Center's Experience with 1100 Free Tissue Transfers

Over 1100 free tissue transfers (FTT) have been performed at the authors' institution. The first 100 were performed using the operating microscope. With rare exceptions, the next 1000 free flaps were performed using X3.5 loupes only. The study population included all FTTs between 1992 and 2003 using loupes only. Hospital and office charts were reviewed, comprehensively evaluating demographics, defect, flap, hospital and postoperative course, with attention to anastomotic complications and flap success.

During a 10-year period, 1027 free flaps were performed on 961 patients, 73% female and 27% male. The FTTs were used for breast (58.8%), head and neck (21.2%), lower extremity (17.9%), upper extremity (1.7%), and for trunk-abdomen-perineal reconstruction (0.04%). Free flaps included free TRAMS (56%), rectus abdominis muscle (11.7%), radial forearm flaps (9.3%), fibula (5.0%), latissimus dorsi muscle (3.9%), and others. Ninety-one percent of microanastomoses were performed by one supervising surgeon; 98% of venous anastomoses and 85% of arterial anastomoses were performed with interrupted 9-0 nylon. There were no couplers used in this study. Forty-nine percent of the FTTs were performed at two university hospitals, and 51% were performed at 6 community hospitals.

The intraoperative arterial thrombosis rate was 3.5%, and the venous thrombosis rate was 1.1%. The arterial thromboses were treated with repeat anastomosis (69%), vein grafting (19%), and thrombolytics (11%). Intraoperative venous thromboses were treated with repeat anastomosis (73%) and vein grafting (17%). The postoperative arterial thrombosis rate was 0.7%, and the venous thrombosis rate was 1.7%. Of the flaps diagnosed with intraoperative thrombosis (4.6%), there was only one subsequent flap loss. Of the flaps diagnosed with postoperative thrombosis (2.2%), there were 6 total flap losses. The relative risk of flap loss from postoperative vascular thrombosis, compared to intraoperative vascular thrombosis, was 12-fold. This difference was statistically significant (p = 0.0042), using the Fisher's exact test. The total flap survival rate was 98.7%. Total flap losses included 8 lower extremity, 3 breast reconstruction, and 2 head and neck reconstruction.

This one center's loupes-only broad spectrum microsurgical experience demonstrated: 1) that loupes are as effective and reliable as the microscope, when comparing flap success rates, and they offer portability in the community setting; 2) that while intraoperative microvascular thrombosis has historically signaled eventual flap thrombosis or problems, this series demonstrated that intraoperative correction leads to very satisfactory results; 3) that when thromboses occurred, they were effectively corrected using loupes-only for magnification.