Lithotomy Position for DIEP Flap Elevation in Immediate One-Stage Breast ReconstructionFunding None.
20 September 2019
29 September 2019
21 November 2019 (online)
Autologous microvascular breast reconstruction is one of the gold standards for reconstructive options, and the deep inferior epigastric perforator (DIEP) flap is most frequently used.   Immediate one-stage breast reconstruction has the advantage of improved aesthetic outcomes, fewer surgical procedures, shorter treatment period, a higher quality of life, and psychological well-being.  Although the DIEP flap is the workhorse flap even in immediate one-stage breast reconstruction, the drawbacks of the procedure may include the crowed situation during the flap elevation and prolonged operation time, probably because breast surgeons and plastic surgeons interfere with each other when they operate at the same time. We suggest a simple and effective method to less the cramped situation by positioning the patient in a lithotomy position.
In the DIEP flap harvest, plastic surgeons typically stand on both sides of the patient who is in the supine position.  However, in immediate one-stage breast reconstruction, breast surgeons also stand on both sides of the patient during tumor excision, and there is not enough room for all surgeons to concentrate on their work, especially when the patient is short. Inadequate working space makes surgeons feel distressed, and some plastic surgeons may choose to start flap elevation after tumor excision to avoid the crowded situation; all these may result in a prolonged surgical time.
We introduce an efficient solution to this problem, lessening the cramped situation and shortening the total operative duration. The patient is positioned in a lithotomy position, and breast surgeons stand on both sides of the patient as usual. The plastic surgeon stands between the patient's legs, and harvests the flap by himself/herself ([Fig. 1]). An assistant may sometimes help the operator from the operator's side if necessary.
This approach allows both breast surgeons and plastic surgeons to do their work at the same time without straining themselves because each surgeon has enough space. Moreover, this position may also facilitate tension-free closure of the donor site by flexing the patient's hip joints.
The limitation of this method is the relative difficulty in elevating the flap, because the plastic surgeon is supposed to do all or most of the procedure by himself/herself, and the operator may need to get used to it. Utilization of surgical instruments, such as hook retractors and self-retaining retractors, is helpful in this technique. Despite the limitation, our method is a simple and effective way to reduce cramped and stressful situations for both breast surgeons and plastic surgeons, possibly shortening the total operation time.
This report was published with the consent and permission of the patients involved.
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