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The Risky Positions Ofdiepflapbreast Reconstruction: A Pilot
Christin A. Harless, Md, Tianke Wang, MS, Katherine E. Law, PhD, Susan Hallbeck, PhD, Minh-Doan Nguyen, MD, PhD.
Mayo Clinic, Rochester, Rochester, MN, USA.

Background: Autologous breast reconstruction in the form of a deep inferior epigastric flap (DIEP) requires long operative times and advanced microsurgical skills. Throughout the operations surgeons are often required to sustain awkward or uncomfortable positions to effectively access perforators, harvest the flap, reconstruct the breast(s), and repair the abdomen. This study aims to (1) quantify surgeon postures during DIEP flap procedures and (2) evaluate surgeons' exposure to risks associated with MSD throughout three main sections of the surgery including: abdominal flap dissection, chest dissection, and microvascular anastomosis.
Methods: Surgeons wore inertial measurement units (IMUs) placed on the head, back of the torso, right upper arm, and left upper arm to quantify their postures during DIEP flap procedures. Mean angles of surgical postures and ergonomic risk scores using Rapid Upper Limb Assessment (RULA) were determined across the procedural phases according to limb angle and duration of sustained angle (Figure 1). On a scale from 1 to 4, scores >2.5 were considered Ďat risk' of MSD. Analysis of variance tests were performed with a significance level of 0.05 on the average RULA risk scores across the phases of the surgery by IMU location (head, torso, right upper arm, left upper arm).
Results: Two surgeons donned IMUs during five bilateral DIEP flap cases (M=467 min, SD=86). Overall RULA risk scores ranged from 1.17 to 2.70. Neck positions that surgeons sustained during the abdominal flap dissection and chest dissection presented the highest risk to surgeons (M=2.81 points, SD=2.67), followed by the torso risk score (M=2.02 points, SD=2.17) (Figure 2). These were statistically significantly higher than during microvascular anastomoses (p=0.001). Use of the microscope during the anastomosis section presented low ergonomic risk in all body parts studied.
Conclusions: DIEP flap procedures present significant ergonomic risks that may lead to musculoskeletal disorders as shown by high risk postures sustained over long durations for the surgeon's neck and torso during the flap and chest dissection portions of the procedure. Further interventions should focus on the improving surgeon posture during these portions of the surgery.
Figure 1. Rapid Upper Limb Assessment (RULA) Risk according to Neck and Torso
Figure 2. Average Rapid Upper Limb Assessment (RULA) Risk Score by Procedural Phase


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