From the Department of Plastic Surgery, University of Virginia Health System; the Department of Surgery, Division of Plastic Surgery, and the Department of Orthopedic Surgery, University of Pennsylvania Health System; and the Department of Plastic Surgery, New York University Langone Health.
Plast Reconstr Surg. 2020 Jan;145(1):235-240. doi: 10.1097/PRS.0000000000006381.
Although the surgical microscope remains the most common tool used for visual magnification for microsurgical anastomoses in free tissue transfer, loupe-only magnification for free flap breast reconstruction has been demonstrated to be safe and effective. To evaluate the loupe-only technique in lower extremity free flap reconstruction, the authors compared perioperative outcomes between microsurgical anastomoses performed with loupe magnification versus a surgical microscope.
The authors conducted a two-institution retrospective study of soft-tissue free flaps for traumatic below-knee reconstruction. Optimal subgroup matching was performed using patient age, defect location, flap type (muscle versus fasciocutaneous), and time from injury (acute, <30 days; remote, >30 days) for conditional logistic regression analysis of perioperative outcomes.
A total of 373 flaps met inclusion criteria for direct matched comparison of anastomoses performed with loupe magnification (n = 150) versus a surgical microscope (n = 223). Overall major complication rates were 15.3 percent: take-back for vascular compromise, 7.8 percent; partial flap failure, 7.8 percent; and total flap loss, 5.4 percent. No differences were observed between the loupe and microscope groups regarding major complications (14.0 percent versus 16.1 percent; OR, 0.78; 95 percent CI, 0.38 to 1.59), take-back for vascular compromise (5.3 percent versus 9.4 percent; OR, 0.51; 95 percent CI, 0.19 to 1.39), any flap failure (13.3 percent versus 13.0 percent; OR, 1.21; 95 percent CI, 0.56 to 2.64), partial flap failure (7.3 percent versus 8.1 percent; OR, 1.04; 95 percent CI, 0.43 to 2.54), and total flap loss (6.0 percent versus 4.9 percent; OR, 1.63; 95 percent CI, 0.42 to 6.35).
Perioperative complication rates, take-backs for vascular compromise, partial flap losses, and total flap failure rates were not significantly different between the matched loupe and microscope groups. Overall microsurgical success rates in traumatic lower extremity free flap reconstruction appear to be independent of the microsurgical technique used for visual magnification.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
尽管手术显微镜仍然是游离组织移植中用于显微吻合的最常用的视觉放大工具，但已经证明在游离皮瓣乳房重建中仅使用放大镜进行放大是安全有效的。为了评估在下肢游离皮瓣重建中仅使用放大镜的技术，作者比较了使用放大镜放大进行显微吻合与使用手术显微镜进行显微吻合的手术结果。
作者对两家机构的外伤性膝关节以下重建的软组织游离皮瓣进行了一项回顾性研究。使用患者年龄、缺损部位、皮瓣类型（肌肉皮瓣与筋膜皮瓣）和受伤时间（急性，<30 天；陈旧性，>30 天）进行最优亚组匹配，对手术结果进行条件逻辑回归分析。
共有 373 个皮瓣符合直接比较放大镜（n = 150）与手术显微镜（n = 223）吻合的条件。总的主要并发症发生率为 15.3%：血管并发症导致的再手术为 7.8%，部分皮瓣失败为 7.8%，全层皮瓣坏死为 5.4%。放大镜组与显微镜组之间在主要并发症方面无差异（14.0%与 16.1%；OR，0.78；95%CI，0.38 至 1.59），血管并发症导致的再手术（5.3%与 9.4%；OR，0.51；95%CI，0.19 至 1.39），任何皮瓣失败（13.3%与 13.0%；OR，1.21；95%CI，0.56 至 2.64），部分皮瓣失败（7.3%与 8.1%；OR，1.04；95%CI，0.43 至 2.54），全层皮瓣坏死（6.0%与 4.9%；OR，1.63；95%CI，0.42 至 6.35）。
在匹配的放大镜与显微镜组之间，手术并发症发生率、血管并发症导致的再手术、部分皮瓣损失和全层皮瓣坏死的发生率没有显著差异。外伤性下肢游离皮瓣重建的整体显微吻合成功率似乎与用于视觉放大的显微技术无关。
临床问题/证据水平：治疗性，III 级。
