Loupes vs. Microscopes in Microvascular Free Tissue Transfer Surgeries: A Systematic Review and Meta‐Analysis

Abstract Objective Reconstructive surgeons have been utilizing free tissue flaps to reconstruct defects from tumor excision since the late 1950s. Many advancements have been made since, and the most common forms of magnification are operating microscopes and loupes to anastomose the vessels from the donor and recipient sites. Data Sources Studies reporting the usage of loupes and microscopes on free tissue flaps utilization were identified using predefined inclusion criteria from 1995 to 2024 from Scopus, PubMed, Embase, MEDLINE, Web of Science, and CENTRAL databases. Review Methods A systematic search was conducted using the PRIMSA guidelines, yielding a total of 262 articles, 11 of which met the inclusion criteria. All studies underwent a 2‐stage blinded screening, extraction, and evaluation process. Primary outcomes were flap survival rate based on patients undergoing microvascular surgery or reconstruction using a surgical loupe or operating microscope. Secondary outcomes included operation time, anastomosis time, hospital stay, arterial and venous thrombosis rate, and overall complication rate. Results On average, Loupes showed a reduced operative time compared to microscopes (482 vs 619 minutes; Loupes vs microscope). Using Fisher's exact test, loupes demonstrated significantly lower rates of overall complication (6.0% vs 15.3%) and overall flap loss (2.7% vs 7.0%) ( P < .0001), as well as reduced complete flap loss (1.7% vs 4.9%, P < .01) and partial flap loss (4.0% vs 8.1%, P < .05). Forest plot analysis consistently favored loupes across all outcomes. Conclusion The parameters that we identified to favor loupes are vital metrics in microscopic flap surgery. Flap failure can have consequences on patients, including longer ICU and hospital stays, increased mortality, and worsened functionality outcomes.