Patient retraction trauma
5–14% skin-flap necrosisIn order for the surgeon to achieve direct line-of-sight visualization, an assistant holds sustained tension on the skin flap. This forceful retraction is a recognized driver of skin flap and NAC necrosis, leading to post-operative complications.
Surgeon injury
>50% report career-affecting painDissecting with direct line-of-sight visualization forces non-anatomic and painful operating posture. Over the course of a surgical career, the cumulative physical strain causes chronic injury and early attrition.
Surgical education
Only one person can see the operative fieldThe dissection happens through a small incision in a deep, dark cavity, so only the operating surgeon has a line of sight. Residents and fellows can't see what the attending sees, which makes the procedure difficult to teach and slow to learn.