Sunday, October 10, 2004

Loupes For Magnification: One Center's Experience With Over 1000 Free Tissue Transfers

Stephen J. Vega, MD, Shao Jiang, MD, Hani Sbitany, Andrew Smith, Assistant Professor, Division of Plastic Surgery, and Joseph Serletti, Chief, Division of Plastic Surgery.

INTRODUCTION: Over 1100 Free Tissue Transfers (FTT) have been performed at our Institution. The first 100 were performed using the operating microscope. Loupes for anastamotic magnification was initiated because of the greater degrees of freedom they offered to the surgeon. With very rare exception these next 1000 free flaps were performed using 3.5x loupes only for magnification. METHODS: The study population includes all patients who underwent FTT at our teaching institution and its affiliates from 1992-2003 using loupes only. Hospital and office charts were reviewed retrospectively, looking comprehensively at demographics, defect, flap, hospital and postoperative course, with particular attention to anastamotic complications, and flap success. RESULTS: During a 10 year period, 1027 free flaps were performed on 961 patients, 73% female (701) 27% male (260). FTT were performed for breast reconstruction 58.8% (604), head and neck reconstruction 21.2% (218), lower extremity reconstruction 17.9% (184), upper extremity reconstruction 1.7% (17), trunk-abdomen-perineal reconstruction 0.04% (4). Free flaps included the free TRAM flap 56% (575), the rectus abdominis muscle 11.7% (120), the radial forearm flap 9.3% (96), the fibula 5.0% (51), the latissimus dorsi muscle 3.9% (40), the superior gluteal muscle 2% (21), the VRAM flap 1.2% (12), the SGAP flap 1% (10), the DIEP flap 1.0% (10), the omentum 0.6% (6), the lateral arm 0.4% (4), the scapular flap 0.5% (5), the serratus muscle 0.3% (3), the jejunum 0.3% (3), the gracilis 0.1%. 91% of microanastamoses were performed by one supervising surgeon while the remaining 11% were performed by another supervising surgeon. 98% of venous anastamoses and 85% of arterial anastamoses were performed with interrupted 9.0 nylon. The remainder were sewn with 8.0 nylon. There were no couplers used in this study. 49% of free flaps were performed at two university hospitals, and 51% were performed at 6 community hospitals. Intraoperative arterial thrombosis rate was 3.5% (36). Intraoperative venous thrombosis rate was 1.1% (11). Intraoperative arterial thromboses were treated with repeat anastamosis 69% (25), vein grafting 19% (7), and thrombolytics 11% (4). Intraoperative venous thromboses were treated with repeat anastamosis 73% (8), and vein grafting 17% (3). Postoperative arterial thrombosis rate was 0.7% (7). Postoperative venous thrombosis rate was 1.7% (17). Of the flaps diagnosed with intraoperative arterial or venous thrombosis 4.6% (47), there was only 1 subsequent flap loss. Of the flaps diagnosed with postoperative venous or arterial thrombosis 2.2% (23), 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 Fisherís exact test. Total flap survival rate was 98.7%. Total flap losses included 8 lower extremity, 3 breast reconstructions and 2 head and neck reconstructions. CONCLUSION: One centerís broad spectrum microsurgical experience using loupes-only for magnification demonstrates: 1) Loupes are as effective and reliable as the microscope when comparing flap success rates, and offer portability to the community setting. 2) While intraoperative microvascular thrombosis has long been considered an ominous sign for eventual flap thrombosis or problems, our series demonstrates that intraoperative correction leads to very satisfactory results. 3) When thromboses did occur, they were effectively corrected using loupes-only for magnification.