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

Pannucci, Christopher J.; Basta, Marten N.; Kovach, Stephen J.; Kanchwala, Suhail; Wu, Liza C.; Serletti, Joseph M.

doi:10.1055/s-0035-1556053

Cited by 32 publications

(11 citation statements)

References 26 publications

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“…Interestingly, in this patient series, we had a relatively high rate of intraoperative revision (16.7%). While this is in-line with other reports on unilateral LAP flaps (17%–22%), 3 , 10 it is higher than most other reports for alternative flap options: 3.4%, 11 7.7%, 12 8.3%, 13 17%, and 27%. 14 This rate is significantly higher than our intraoperative revision rate with other flaps (10% total, 9.2% arterial, and 2.4% venous) ( P < 0.05).…”

Section: Discussionsupporting

confidence: 91%

Lumbar Artery Perforator Flap: Initial Experience with Simultaneous Bilateral Flaps for Breast Reconstruction

Haddock

Teotia

2020

Plastic and Reconstructive Surgery - Global Open

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Background: The lumbar artery perforator (LAP) flap is a useful alternative for patients who are not a candidate for breast reconstruction using the deep inferior epigastric perforator flap. Due to the positioning and concerns for prolonged ischemia time, bilateral breast reconstruction using LAP flaps is frequently performed in separate stages. We present our early experience performing simultaneous LAP flaps for bilateral breast reconstruction. Methods: We performed a retrospective review of all patients who underwent breast reconstruction with LAP flaps from December 2018 to September 2019. Demographics, flap data, and complication data were collected. Surgical sequence is presented. Results: A total of 30 simultaneous bilateral breast reconstruction were performed with LAP. We experienced 1 flap loss in an undiagnosed hypercoagulable patient. The average patient age was 52.7 years, and the average body mass index was 26.9. Most patients had a surgically absent abdominal donor site (66.7%). The average operative time was 510 minutes and ischemia time was 90.3 minutes. All flaps were performed using a composite deep inferior epigastric arterial/venous graft. Conclusions: The LAP flap is an innovative, yet technically challenging, choice for autologous breast reconstruction. In our experience, simultaneous bilateral breast reconstruction using LAP flaps can be safely performed in a single surgical stage; however, we recommend caution and a coordinated team approach. With simultaneously performing bilateral LAP flaps, there is an inherent prolonged ischemia time and, thus, an increased possibility for vasospasm and intraoperative revisions. This experience represents the first series of bilateral LAP flaps performed simultaneously.

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Section: Discussionsupporting

confidence: 91%

Lumbar Artery Perforator Flap: Initial Experience with Simultaneous Bilateral Flaps for Breast Reconstruction

Haddock

Teotia

2020

Plastic and Reconstructive Surgery - Global Open

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“…[22]. Furthermore, according to our practice, we noticed that 3.5X loupes, when compared with the 10x microscope, signi cantly shortened the surgery time, which was consistent with Pannucci's study [23].…”

Section: Learning Curve Of Ms-tram/diep Surgerysupporting

confidence: 89%

The feasibility of nipple-sparing mastectomy in combined with abdominal free flap breast reconstruction without skin paddles for flap monitoring: a single-center experience

Zhu

Chen

et al. 2023

Preprint

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Background Nipple-sparing mastectomy in combination with buried abdominal free flap breast reconstruction without leaving any skin paddles for post-operative monitoring might be associated with better cosmetic outcomes. The feasibility of this approach remains unclear while a detailed and validated protocol of post-operative flap monitoring is lacking. Materials and Methods Eligible patients receiving abdominal free-flap breast reconstruction between 2015 and 2020 in our institution were included. Patients were categorized into the buried-flap cohort and the skin-paddle cohort based on whether a skin paddle remained for direct visual monitoring post-operatively. We reported the learning curve of this surgery and the determinants of operative and/or ischemic time. The oncological outcomes and surgical complications rates were also analyzed. Results This study included 147 eligible patients (buried-flap cohort: N = 18; skin-paddle cohort: N = 129). In early-stage patients with immediate breast reconstruction (N = 104), there were no observed relapse events with a median follow-up time of 18 months. The learning curve analysis showed significant reduction of the surgery time and the ischemic time with accumulation of surgical experience after 30 cases. The surgery time and ischemic time were significantly shorter in the buried flap cohort, when compared to that of the skin-paddle cohort. The take-back surgery rates, flap failure rates, and other complication rates were similar between two cohorts under the intra- and post-operative monitoring protocol. Conclusion This study supported the feasibility of autologous abdominal free-flap breast reconstruction using the buried flap approach, and we validated our intra- and post-operative monitoring protocol. A multicenter and prospective study is needed to validate this approach. Trial registration：NCT05560633

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“…One example of this is the incorporation of loupe microsurgery for the first set of anastomoses. 21 There was a slight learning curve related to this modified technique, and as a result an early increase in intraoperative revisions. Although these revisions did produce a significant change in operative time, it had a limited overall impact toward time.…”

Section: Discussionmentioning

confidence: 98%

Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours

Haddock

Teotia

2021

Plastic and Reconstructive Surgery - Global Open

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Introduction:The DIEP flap is considered the gold standard in autologous breast reconstruction. Despite the benefit of a lifelong natural reconstruction, some argue that the potential drawbacks, specifically operative time and recovery, are significant. We recently focused specifically on process analysis in our DIEP flap practice and present a comprehensive analysis in efficient DIEP flap breast reconstructions. Methods: Fifty consecutive bilateral DIEP flaps were prospectively tracked (100 flaps). The procedure was divided into segments (recipient site preparation, DIEP flap dissection/harvest, microsurgery, breast shaping, and abdominal closure). All individual step times were recorded for each team member. Relevant patient characteristics, intraoperative details and postoperative outcomes were recorded. Results: Average surgical time was 3 hours and 58 minutes (the fastest time recorded was 2 h and 14 min). There were no immediate postoperative complications. The anastomotic revision rate was 6%. Four surgeons contributed 34.7% of the time, three surgeons 32.2% of the time, two surgeons 23.6% of the time, and one surgeon 4.8% of total time. In procedures under 4 hours, four surgeons contributed simultaneously 36.7% of the time compared to 21.8% in the longer procedures (P = 0.004). Four surgeons contributed 45.4% of the time (P = 0.01) in the subthree-hour bilateral DIEP flap procedures. Conclusions: Efficient DIEP flap breast reconstruction can be accomplished with a well-trained and coordinated team approach involving like-minded surgeons with extensive experience working together. The synergistic map shows constant movement with utilization of hidden time, without sacrificing education, outcomes, or innovation.

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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

Abstract: 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.

Cited by 32 publications

References 26 publications

Lumbar Artery Perforator Flap: Initial Experience with Simultaneous Bilateral Flaps for Breast Reconstruction

Lumbar Artery Perforator Flap: Initial Experience with Simultaneous Bilateral Flaps for Breast Reconstruction

The feasibility of nipple-sparing mastectomy in combined with abdominal free flap breast reconstruction without skin paddles for flap monitoring: a single-center experience

Efficient DIEP Flap: Bilateral Breast Reconstruction in Less Than Four Hours

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