Loupes-only microsurgery.

Standard magnification in microsurgery is accomplished with the operating microscope. Loupes are perceived by the microsurgical community as technically less safe. However, after several years of microscope-only microsurgery, most of our microvascular procedures are performed under loupes 3.5-4x. Considering our results using loupes-only microsurgery, which are comparable with those obtained when using the microscope, we suggest that loupe-aided microsurgery might represent a natural progression for the experienced microsurgeon. Microsurgical skills and experience outweigh the importance of the magnification factor. While the microscope is mandatory for replantations distal to the palmary arch, microneurosurgery, and supramicrosurgery, loupes should be used in so-called "macro-microsurgery." One may include in this category replantations down to the palmar arch and free flaps with vessels more than 1.5 mm, such as the latissimus, serratus, (para)scapular, fibula, radial forearm, rectus abdominis, dorsalis pedis, omentum, and jejunum. Before starting loupes-only microsurgery, intensive training under the microscope is crucial. Less magnification does not mean less quality.