Loupes have long been an integral part of the microsurgeon's arsenal, playing an instrumental role in the provision of intricate details. The prismatic lens of the spectacle model may exert enormous and prolonged pressure upon the delicate skin of the nasal bone which lacks a sufficiently thick layer of subcutaneous fat. A simple yet brilliant innovation has been developed that incorporates the principle of offloading to integrate a corn cap into a soft nasal support. This simple technique could prove invaluable to microsurgeons suffering from nasal discoloration or pain following prolonged use of prismatic loupes. The pressure exerted on the nose is reduced by 42% with this technique.
Loupes play an essential role in the arsenal of a microsurgeon, since they allow for fine details to be observed under the loupes . Presently, two types of loupe lenses are available for microsurgeons, prismatic loupes and Galilean loupes. The weight of a prismatic loupe ranges between 100 and 160 grams, which is significantly more than the weight of a Galilean loupe. In plastic surgery, prismatic loupes are more preferred over Galilean loupes for their higher precision and enhanced focus when performing repair of extremely intricate structures .
The prismatic loupe can be classified into two types. The first is a headband, while the second is a pair of spectacles . Although the headband model is advantageous in that it does not readily cause fogging of the lens, it can cause headaches for certain individuals because of its bulkiness. While the spectacle model is smaller and more compact, its greatest disadvantage is that the majority of the weight for the lens system is located near the proximal part of the lateral wall of the nose.
A pair of prismatic spectacles exert considerable pressure on the delicate skin surrounding the nasal bone, which lacks a sufficient covering of subcutaneous fat. Numerous surgeons find that after wearing prismatic spectacles continuously for a lengthy period of time, they develop permanent signs of pressure-induced deformation and discoloration of the skin (as in the case of the author). This causes certain aspiring plastic surgeons to develop a subconscious aversion to loupes when undergoing prolonged surgery. An additional issue with this model is that it can cause users to experience frontal headaches after prolonged use.
There may be a benefit to using nose pads to alleviate the problem of loading caused by microsurgical loupes. The most commonly available nose pads that are intended for use with regular spectacles are made of silicone rubber. However, the sheer weight of the loupe may make the nose pads ineffective at providing adequate relief from pressure pain on the nose. Another issue faced by the majority of surgeons is the necessity to replace the nose pads on a frequent basis.
The author demonstrates one simple innovation that incorporates the offloading principle and integrates a corn cap onto the soft nasal support in this article (Figure 1). As the corn cap is inverted, the layer of cloth is on the inner side, and the sheet of silicone is on the outer side. In the following step, the inverted corn cap is divided longitudinally on a midline so that it is split into two equal segments all the way up until it reaches the base in such a way that the segments are attached to the base. The segments of the corn cap are now sewn individually onto the nose pad of the loupe, with the base lying in the midline between the two supports. As opposed to a standard nasal pad or support, the three-sided nasal support system is designed with a larger surface area and better molding flexibility. A corn cap is also able to distribute the weight evenly and prevent skin discoloration and pain because of the pliability of silicone.
Over the last five years, the author has employed this home-made innovation technique for circumventing iatrogenic nasal pressure sores for approximately 38 hours a week. This corn cap has proven to be extremely comfortable to wear and has not yet required any modification or replacement of the silicone material.
As these silicone caps are gel sheets, they conform to the shape of the nose. The silicone sheets act as a sponge when pressed against the rigid surface of the nose. This allows the silicone sheets to increase the surface area and decrease the pressure per unit surface area. A mathematical equation can be used to estimate the weight of the loupe on the lateral wall of the nose.
It has been found that pressure for a given weight is inversely proportional to its projected area. To facilitate calculations, the projected surface area of contact of the nasal support was determined in both cases, with and without the cushion. We employed a simple method whereby the nasal pad was dipped in paint and placed on a graph sheet fitted snugly against the lateral nasal wall. On the graph sheet, the nasal pad was positioned similarly to its position on the nasal walls. Paint was applied on the nasal pad to mark the area of contact. A portion of the paint-marked graph sheet was used to calculate the area of contact by counting the number of millimeter squares. After applying an inverted corn cap, the difference in the area of contact was calculated in a similar manner (Table 1).
On the basis of the equation provided above, pressure (P) is inversely proportional to contact surface area (A), which yields P2/P1 = A1/A2 = 168/288 = 7/12. Taking into consideration the pressure drop, the percentage reduction is equal to (12-7)/12 x 100 = 42%. For microsurgeons using prismatic loupes with nasal pads, this invention might prove extremely useful as a means to support their performance.
With this device, some limitations may be encountered. It is not possible to employ this technique in loupes with headbands, as well as in models without nasal support. It is also worth noting that the silicone caps increase the height of the loupe glass by 1 to 2 mm. Therefore, this feature limits the use of these loupes for individuals with fixed or non-adjustable lenses.
The inverted corn cap offers a simple and inexpensive solution to preventing nasal pigmentation and headaches that may result from long hours of microsurgery performed with loupes. The design of the corn cap conforms to the shape of the nose and distributes the weight of the loupe over a large surface area, thereby reducing pressure and sensations of discomfort on the nose.
Received date: April 13, 2022
Accepted date: June 06, 2022
Published date: July 07, 2022
The manuscript has not been presented at any meetings on the topic.
The study is in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
This research has received no specific grant from any funding agency either in the public, commercial, or not-for-profit sectors.
There are no conflicts of interest declared by either the authors or the contributors of this article, which is their intellectual property.
It should be noted that the opinions and statements expressed in this article are those of the respective author(s) and are not to be regarded as factual statements. These opinions and statements may not represent the views of their affiliated organizations, the publishing house, the editors, or any other reviewers since these are the sole opinion and statement of the author(s). The publisher does not guarantee or endorse any of the statements that are made by the manufacturer of any product discussed in this article, or any statements that are made by the author(s) in relation to the mentioned product.
© 2022 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY). In accordance with accepted academic practice, anyone may use, distribute, or reproduce this material, so long as the original author(s), the copyright holder(s), and the original publication of this journal are credited, and this publication is cited as the original. To the extent permitted by these terms and conditions of license, this material may not be compiled, distributed, or reproduced in any manner that is inconsistent with those terms and conditions.
The communication among international microsurgeons have switched from one direction (from paper, textbook) to multiway interactions through the internet. The authors believe the online platform will play an immensely important role in the learning and development in the field of microsurgery.
Traditionally, suturing techniques have been the mainstay for microvascular anastomoses, but owing to its technical difficulty and labour intensity, considerable work has gone into the development of sutureless microvascular anastomoses. In this review, the authors take a brief look at the developments of this technology through the years, with a focus on the more recent developments of laser-assisted vascular anastomoses, the unilink system, vascular closure staples, tissue adhesives, and magnets. Their working principles, with what has been found concerning their advantages and disadvantages are discussed.
Prof. Koushima, president of World Society for Reconstructive Microsurgery, proposes an innovative concept and technique of the multi-stage ‘Orochi’ combined flaps (sequential flaps in parallel). The technique opens a new vista in reconstructive microsurgery.
The video presents a useful technique for microvascular anastomosis in reconstructive surgery of the head and neck. It is advantageous to use this series of sutures when working with limited space, weak vessels (vessels irradiated, or with atheroclastic plaques), suturing in tension, or suturing smaller vessels (less than 0.8 cm in diameter).
Authors discuss a silicone tube that provides structural support to vessels throughout the entire precarious suturing process. This modification of the conventional microvascular anastomosis technique may facilitate initial skill acquisition using the rat model.
PEDs can be used as alternative means of magnification in microsurgery training considering that they are superior to surgical loupes in magnification, FOV and WD ranges, allowing greater operational versatility in microsurgical maneuvers, its behavior being closer to that of surgical microscopes in some optical characteristics. These devices have a lower cost than microscopes and some brands of surgical loupes, greater accessibility in the market and innovation plasticity through technological and physical applications and accessories with respect to classical magnification devices. Although PEDs own advanced technological features such as high-quality cameras and electronic loupes applications to improve the visualizations, it is important to continue the development of better technological applications and accessories for microsurgical practice, and additionally, it is important to produce evidence of its application at surgery room.
Avulsion injuries and replantation of the upper arm are particularly challenging in the field of traumatic microsurgery. At present, the functional recovery of the avulsion injuries upper arm after the replantation is generally not ideal enough, and there is no guideline for the surgeries. The aim of this study was to analyze the causes of failure of the upper arm replantation for avulsion injuries, summarize the upper arm replantation’s indications, and improve the replantation methods.
The supraclavicular flap has gained popularity in recent years as a reliable and easily harvested flap with occasional anatomical variations in the course of the pedicle. The study shows how the determination of the dominant pedicle may be aided with indocyanine green angiography. Additionally, the authors demonstrate how they convert a supraclavicular flap to a free flap if the dominant pedicle is unfavorable to a pedicled flap design.
The implications of rebound heparin hypercoagulability following cessation of therapy in microsurgery is unreported. In this article the authors report two cases of late digit circulatory compromise shortly after withdrawal of heparin therapy. The authors also propose potential consideration for changes in perioperative anticoagulation practice to reduce this risk.
In a cost-effective and portable way, a novel method was developed to assist trainees in spinal surgery to gain and develop microsurgery skills, which will increase self-confidence. Residents at a spine surgery center were assessed before and after training on the effectiveness of a simulation training model. The participants who used the training model completed the exercise in less than 22 minutes, but none could do it in less than 30 minutes previously. The research team created a comprehensive model to train junior surgeons advanced spine microsurgery skills. The article contains valuable information for readers.
An examination of plastic surgery residents' experiences with microsurgery in Latin American countries was conducted in a cross-sectional study with 129 microsurgeons. The project also identifies ways to increase the number of trained microsurgeons in the region. The authors claim that there are few resident plastic surgeons in Latin America who are capable of attaining the level of experience necessary to function as independent microsurgeons. It is believed that international microsurgical fellowships would be an effective strategy for improving the situation.