Head and Neck Injuries among Powered Scooter Users between 2010 and 2019.

Powered scooters, including electric scooters (e-scooters), have become an increasingly available and popular mode of personal transportation, but the health risks of these devices are poorly explored. We aim to quantify the increase in frequency of powered scooter-associated head and neck region injuries occurring yearly from 2010 to 2019, and to compare the frequency and severity of injury with those involving unpowered scooters. Here we present a retrospective cross-sectional study of all patients with head and neck injuries associated with powered and unpowered scooters seen in emergency departments reporting to the National Electronic Injury Surveillance System (NEISS) database from January 1, 2010 to December 31, 2019. During this time frame, a total of 1,620 injuries associated with powered scooters and a total of 5,675 injuries associated with unpowered scooters were reported to the NEISS. The database estimates these to reflect a nationwide total of 54,036 powered scooter-related injuries and 168,265 unpowered scooter-related injuries. Powered scooter injuries have increased for both children and adults since 2014, and estimated powered scooter injuries (16,243) surpassed estimated unpowered scooter injuries (14,124) when including all age groups for the first time in 2019. In 2019, adults are estimated to have nearly twice as many powered scooter-related head and neck injuries as children (10,884 vs. 5,359, respectively). In 2019, a higher proportion of powered scooter-related injuries involving adults were severe injuries when compared with those involving children (13.3 vs. 5.2%, respectively). Interestingly, unpowered scooters still cause many more estimated injuries in children than powered scooters did during 2019 (11,953 vs. 5,083). We find that powered scooters are now associated with a greater number and severity of head and neck injuries among the adult population than the pediatric population. But unpowered scooters still cause more head and neck injuries than powered scooters in the pediatric population.

Lateral Crural Repositioning: Implications on Nasal Function.

There are many concepts for surgical management of the nasal tip with varying outcomes on esthetics and nasal function. Nasal tip surgery can influence nasal function based on how the techniques can alter lateral wall integrity. A retrospective chart review of rhinoplasty patients undergoing lateral crural strut grafting (LCSG) with and without repositioning from 2009 to 2017 of the primary author (D.M.T.) was performed. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores were analyzed. In our study, 832 subjects were evaluated. The mean preoperative NOSE score of all subjects was 35.48. The longest follow-up mean was 652.07 days with a mean NOSE score of 7.07 (p < 0.0001). In the LCSG group, the mean preoperative NOSE score was 22.97. The longest follow-up mean was 583.29 days with a mean NOSE score of 7.22 (p < 0.0001). In the LCSG with repositioning group, the mean preoperative NOSE score was 43.42. The longest follow-up mean was 692.36 days with a mean NOSE score of 7.60 (p < 0.0001). LCSGs with or without repositioning improves nasal function showing significant improvement in NOSE scores. The use of these techniques require adhering to several technical points to maximize outcomes and to avoid deformity.

Evidence-Based Medicine for Lower Facial Rejuvenation.

Lower facial rejuvenation is an expanding area in facial plastic surgery with both surgical and nonsurgical treatment options. Evidence-based medicine is essential to providing high-quality care and creating long-lasting results. A systematic approach and understanding of the layers of the aging lower face is important to develop an individualized treatment plan. This review will focus on surgical and nonsurgical treatments for the aging lower face with an emphasis on evidence-based medicine.

Blinded Evaluation of Hyaluronic Acid Hand Filler Injections and Effects on First Impressions.

BACKGROUND: The hands are the second most common body part visible after the face. In the aging hand, the dorsum loses volume, becomes uneven, veins become more prominent, and there is an increase in spots and wrinkles. OBJECTIVE: To determine the effects of large-particle hyaluronic acid filler injection into the dorsal hand on first impressions. MATERIALS AND METHODS: Ten subjects underwent filler injections in the bilateral dorsal hands with large-particle hyaluronic acid filler. Photographs of the hands were taken at baseline and 2 weeks after the optimal correction result. A survey to evaluate first impressions was then completed by blinded evaluators on defined categories of perception. RESULTS: A total of 209 evaluators completed the first impression questionnaire. Overall, 10,032 individual assessments of first impressions were completed. There was a significant improvement in mean first impressions in all categories of perception and overall first impression scores. CONCLUSION: Cosmetic treatments to the hands is a growing field with the use of hyaluronic acid fillers to restore volume, decrease wrinkles, and improve the appearance of prominent veins. This study revealed an improvement in first impression scores in all categories following treatment with large-particle hyaluronic acid filler to the dorsal hands.

Evaluation of Selfies and Filtered Selfies and Effects on First Impressions.

BACKGROUND: Selfies and filtered selfies are becoming more prevalent throughout society and in the facial plastic surgery clinic. The term "Snapchat dysmorphia" has been used to describe patients seeking procedures to look like their selfie or filtered selfie. This is particularly frequent in the Millennial population, aged 22 to 37 years. OBJECTIVES: The authors sought to determine the effects on first impression from different photograph types: selfies, filtered selfies, a rear-facing smartphone camera, and a digital camera (DC). We hypothesize that the DC photographs will have the highest rated first impressions among evaluators despite the popularity of selfies and filtered selfies. METHODS: This study included 240 evaluators and 4 patients each completing the 4 different photograph types. The evaluators completed a survey rating first impression on various measures of success for each photograph type. RESULTS: A total of 960 first impressions were recorded for each of the 8 subscales, yielding 7680 individual assessments of first impression. The DC photograph was found to have the highest first impression scores among the 4 photograph types. There was no statistical difference between selfies and filtered selfies. The rear-facing smartphone camera received the lowest first impression scores. CONCLUSIONS: Our findings indicate that the standard DC photograph taken during a preoperative consultation has higher first impressions than selfies or filtered selfies. Although "Snapchat dysmorphia" may continue to be a growing trend in the near future, our findings provide important information to discuss with patients in the preoperative visit to set realistic expectations.

A Randomized, Single-Blind, Crossover Study Evaluating the Impact of OnabotulinumtoxinA Treatment on Mood and Appearance During the COVID-19 Pandemic.

BACKGROUND: The emergence of COVID-19 led rapidly to one of the most severe disease outbreaks in modern history. This caused many aesthetic practices to close temporarily, providing a unique opportunity to evaluate the impact of neurotoxin use in the setting of an ongoing pandemic. OBJECTIVES: The aim of this study was to examine whether administration of onabotulinumtoxinA (BOTOX Cosmetic, Allergan plc, Dublin, Ireland) to regular users synergistically amplifies the elevation in mood/happiness, self-satisfaction with appearance, and overall satisfaction in the context of the ongoing pandemic. METHODS: A randomized, single-blind, crossover study was designed to evaluate the impact of neurotoxin treatment in the upper third of the face on mood, self-satisfaction with appearance, and overall satisfaction. The placebo group crossed over to treatment after 1 month. Surveys evaluating patient happiness, self-satisfaction with appearance, and overall efficacy were completed by both groups, and again by the placebo group following crossover to treatment. RESULTS: Forty-five subjects were enrolled: 30 in the treatment group and 15 in the control/crossover group. The placebo group demonstrated no change in happiness or self-satisfaction in appearance until crossover to the treatment group. Both groups, once receiving onabotulinumtoxinA, reported increased happiness, self-satisfaction with appearance, and overall treatment satisfaction. CONCLUSIONS: OnabotulinumtoxinA treatment to the upper face in the midst of the COVID-19 pandemic was found to increase patient happiness, self-satisfaction with appearance, and overall treatment satisfaction.

Perception of Beauty in the Visually Blind: A Pilot Observational Study.

BACKGROUND: Blind individuals have demonstrated the ability to detect danger and facial expressions without conscious awareness of visual stimuli. These embodied sensations are believed to be the result of primitive neural networks refined by evolutionary adaptations. We postulate that similar embodied sensations may have evolved to allow blind individuals to perceive beauty. OBJECTIVE: To determine whether the visually blind can detect physical beauty. PATIENTS AND METHODS: This observational study consisted of 8 blind and 10 nonblind test subjects and 6 models that were categorized into predetermined beauty categories. Test subjects were individually asked to rate 6 models on a 1 to 10 numerical beauty scale. This process was repeated in both groups while blindfolded (masked). All groups' mean model beauty scores underwent multivariate and univariate analysis. RESULTS: All groups rated preselected (greater than 8) more beautiful models, higher except for the masked, nonblind group. Intraclass correlation was good in the blind raters with a score of 0.751, whereas poor in the nonblind masked raters with a score of 0.458. CONCLUSION: This is the first pilot study demonstrating with supporting evidence that blind individuals can detect beauty and supports that beauty may rely on primal forms of messaging that are subconsciously appreciated.

Lower Blepharoplasty Three-Dimensional Volume Assessment after Fat Pad Transposition and Concomitant Fat Grafting.

Lower blepharoplasty is a commonly performed procedure to improve the aesthetic of the lower eyelid and upper midface. Combined fat pad transposition and fat grafting has not been previously studied using three-dimensional (3D) analysis. The aim of the study is to demonstrate the benefits of fat pad transposition with concomitant autologous fat grafting in lower blepharoplasty and to determine quantitative volumetric effects on the tear trough and lower periorbital region using VectraXT 3D imaging and analysis. A retrospective review was performed to identify patients undergoing primary lower blepharoplasty with combined fat pad transposition and fat grafting. The study time period was from September 2017 to March 2019 with a mean 6.5-month postoperative follow-up. This study was performed in a private practice institution (Kovac Cosmetic Center, Oakbrook Terrace, IL). Nine subjects were enrolled in the study with four males and five females. All subjects underwent lower blepharoplasty with combined fat pad transposition and fat grafting without any additional procedures. Preoperative and postoperative photographs were taken with the VectraXT 3D camera system and software. 3D photographs were then compared to assess the volume changes in the periorbital region. The volume in the lower periorbital region was assessed using 3D analysis. All subjects were found to have an increase in volume in the periorbital region. There was a mean volume gain of 2.84 mL on the right and 2.87 mL on the left. There was no statistical difference among volume gains between sides (p = 0.95). Combined fat pad transposition and autologous fat grafting is an effective procedure for improving the tear trough deformity and periorbital area. The use of 3D volume assessment is able to accurately measure and quantify the volume changes of the postoperative results.

Quality and Reliability of YouTube for Patient Information on Neurotoxins.

YouTube is a common source of medical information for patients. This is the first study to assess the reliability and educational value of YouTube videos on neurotoxin procedures. YouTube.com was searched on June 15, 2020 using the keyword "Botox" or "neurotoxin." A total of 100 videos were reviewed. Sixty-one videos met the inclusion criteria and were included in the final analysis. Video characteristics were noted, and a score was assigned to each video using the Journal of the American Medical Association (JAMA) benchmark criteria and the Global Quality Score (GQS) to measure source reliability and educational value, respectively. A total of 61 videos that met the inclusion criteria had an average length of 589 seconds (9 minutes and 49 seconds), 210,673 views, 5,295 likes, 318 dislikes, and 478 comments. A total of 30 videos (49%) were posted with an intention to educate patients while 31 videos (51%) were posted with the intention to detail a personal experience with neurotoxin. Patient education videos were significantly more reliable (P JAMA< 0.001) and had more educational value (P GQS < 0.001) but were less popular than "personal experience videos." Personal-experience videos posted by patients had higher popularity, more likes and comments, yet lower scores on reliability and education. Patients will continue to seek educational material online, and clinicians should utilize this information to help primarily educate patients with standardized and accurate information about their treatment. KEY POINTS: · Question: Are YouTube videos pertaining to neurotoxin reliable and contain useful information to educate patients to make informed decisions about their neurotoxin treatment?. · Findings: Roughly half of videos reviewed were vlogs (video logs), which were of low quality and educational value, but were more popular compared with videos that were intended to educate patients on neurotoxin treatment.. · Meaning: Patients who use YouTube as a source of information about neurotoxin treatment may be misled with inaccurate and unreliable information. Physicians must be aware of these findings to properly educate patients with standardized and accurate information about their treatment..

The expression of RUNDC3B is associated with promoter methylation in lymphoid malignancies.

DNA methylation is an epigenetic modification that plays an important role in the regulation of gene expression. The function of RUNDC3B has yet to be determined, although its dysregulated expression has been associated with malignant potential of both breast and lung carcinoma. To elucidate the potential of using DNA methylation in RUNDC3B as a biomarker in lymphoid malignancies, the methylation status of six regions spanning the CpG island in the promoter region of RUNDC3B was determined in cancer cell lines. Lymphoid malignancies were found to have more prominent methylation and did not express RUNDC3B compared with myeloid malignancies and solid tumours, supporting the potential use of DNA methylation in this region as a biomarker for lymphoid malignancies. RUNDC3B contains a RUN domain in its N-terminal region that mediates interaction with Rap2, an important component of the mitogen-activated protein kinase (MAPK) cascade, which regulates cellular proliferation and differentiation. The protein sequence of RUNDC3B also contains characteristic binding sites for MAPK intermediates. Therefore, it is possible that RUNDC3B serves as a mediator between Rap2 and the MAPK signalling cascade. Three genes with MAPK-inducible expression were downregulated in a methylated leukaemia cell line (HSPA5, Jun and Fos). Jun and Fos combine to form the activating protein 1 transcription factor, and loss of this factor is associated with the dysregulation of genes involved in differentiation and proliferation. We hypothesize that the loss of RUNDC3B secondary to aberrant hypermethylation of the early growth response 3 transcription factor binding site results in dysregulated MAPK signalling and carcinogenesis in lymphoid malignancies. © 2015 The Authors. Hematological Oncology published by John Wiley & Sons Ltd.

Quantitative Analysis of Tranexamic Acid Effects on Ecchymosis in Rhinoplasty.

Background: Many methods have been described to reduce postoperative ecchymosis in rhinoplasty with tranexamic acid (TXA) remaining controversial. TXA remains a consideration for surgeons, however, may have serious side effects, including seizures, blood clots, and vision changes. Methods: A prospective study of primary rhinoplasty patients was performed from March 2019 to June 2019. TXA was used in 50 patients and postoperative ecchymosis was compared with 50 control patients. Adobe Photoshop was used to quantitate postoperative ecchymosis using multiple objective color scales. Results: One hundred subjects were enrolled in the study. Eighty-four females and 16 males were included. Photographs were taken on postoperative day 7. There were no significant differences among any of the Red, Green, Blue (RGB) and L*a*b* color subgroups with p > 0.05. There were no adverse events with TXA. Conclusions: In this study, TXA did not reduce postoperative ecchymosis in rhinoplasty when used both through intravenous and intraoperative injections.

Effects of hyaluronic acid filler injection for non-surgical rhinoplasty on first impressions and quality of life (FACE-Q scale).

BACKGROUND: The nose is a central visual feature of the face leading many patients wishing to improve their facial esthetic appearance to undergo rhinoplasty. Increasingly more patients are seeking non-surgical alternatives such as hyaluronic acid filler injections. These treatments have the ability to profoundly impact patients' esthetic appearance and first impressions. OBJECTIVE: To evaluate the effects of hyaluronic acid filler injection in non-surgical nasal augmentation on first impressions, quality of life, and to evaluate treatment efficacy in reducing the height of the nasal dorsal convexity. METHODS: Ten female subjects underwent small-particle hyaluronic acid filler injection into the nasal soft tissues. Photographs of the subjects were taken at baseline and post-treatment after achieving an optimal correction result. Patients reported satisfaction with outcomes using a validated patient-reported outcome measurement tool. Blinded evaluators were used to assess first impressions across specifically defined categories using the baseline and post-treatment photographs. The height of the pre and post-injection nasal dorsal convexity was compared. RESULTS: All patients experienced a statistically significant reduction in the height of their dorsal nasal convexity. There was significant improvement in patient-reported outcomes based on all measures of the FACE-Q scale. A total of 224 evaluators completed blinded assessments of first impressions. Mean first impressions in all eight categories, along with overall first impression score showed statistically significant improvement following treatment. CONCLUSION: Hyaluronic acid filler injections for non-surgical nasal reshaping are a safe and effective method to improve perceived first impressions and to improve patient-reported self-esteem and esthetic satisfaction with their nose.

Analysis of Online Patient Education Materials on Rhinoplasty.

Objective: Are education materials available online appropriate for patients seeking information before rhinoplasty? Study Design: Google.com and YouTube.com were searched for patient education information on rhinoplasty procedures. Of the first 100 results, 75 articles and 75 videos met the inclusion criteria. Each article's readability was scored using six previously validated readability scores to determine patient's ability to comprehend the text, while each video was scored using the Journal of the American Medical Association (JAMA) benchmark criteria and the Global Quality Score (GQS) to measure source reliability and educational value, respectively. Results: Analysis of the readability of the 75 articles yielded an average grade reading level of 10.31 (range 5-20; 95% confidence interval, 9.83-10.79), while video analysis found videos authored by physicians were significantly more reliable (PJAMA < 0.001) and had a significantly higher educational value (PGQS < 0.001). Patient education videos were found to be more reliable than patient experience videos (PJAMA = 0.01). Conclusions: The average reading level for text information on rhinoplasty is higher than the recommended 5th-grade reading level and educational videos authored by physicians are more reliable and contain higher educational value yet lack important information.

Virtual Interviewing Tips for the Otolaryngology Match Cycle During the COVID-19 Pandemic.

Virtual interviews are planned for the upcoming 2020-2021 residency cycle. This presents a unique challenge for medical students. Due to the importance of the interaction of applicants and interviewers during the interview, medical students should thoroughly prepare for the upcoming virtual interview season. We offer practical and realistic concepts and techniques to optimize their interview experience. Technology and audiovisual equipment should be adjusted and enhanced to minimize video conferencing application errors and interview downtime. The applicant's interview environment should focus on proper lighting, background, camera angles, and minimizing unwanted distractions. Mock interview sessions are invaluable to applicants and provide the opportunity to simulate the interview, refine their technology, adjust their environment, and become more comfortable in a virtual interview setting. These actions will prevent unnecessary disruptions and increase the focus of the interview toward the communication between the applicant and the interviewer.

The use of radiofrequency-assisted lipolysis with radiofrequency microneedling in premature jowl and neck laxity following facialplasty.

BACKGROUND: A subset of facelift patients have premature redevelopment of skin laxity in the lower face and neck. Many patients seek alternatives to revision facelifts to avoid high risks and costs. Radiofrequency-assisted lipolysis (RFAL) with Radiofrequency (RF) microneedling may be alternative minimally invasive options. OBJECTIVE/AIM: To evaluate the efficacy of radiofrequency energy devices for treatment of premature jowl and neck skin laxity following facialplasty. METHODS: This is a single-center, prospective study of patients seeking treatment for jowl and neck skin laxity 1-5 years following facialplasty. Treatment was performed with the InMode radiofrequency AccuTite® and Morpheus8® systems. Study duration was 12 months with 6 months of follow-up. Endpoints included improvement in skin tightening assessed by blinded investigators, and investigator and subject assessment of skin appearance. Subjects also rated satisfaction with treatment and pain levels. RESULTS: The study protocol was completed by nine patients. Based on investigator evaluations, 33% had marked improvement at 3 months, which increased to 55% at 6-month postprocedure. Patient-reported improvement was "markedly improved" in 67%, "moderate improvement" in 11%, and "slight improvement" in 22% at 3 months. Overall patient satisfaction was rated as "very satisfied" by 33% and "satisfied" by 67% at 3 months. There were no adverse events reported. CONCLUSION: The results of this study provide supporting evidence that RFAL technology can provide a safe, minimally invasive, and effective treatment for skin laxity in the jowls and neck in patients who desire further correction after undergoing primary facelift.

Evaluation of Postoperative Infection Rates in 3084 Rhinoplasty Cases Using Antibiotic Soaks and/or Irrigations.

Background: Postoperative infections after rhinoplasties are rare, yet devastating on patient outcomes. The literature reports an overall incidence of <2% with higher numbers seen in those requiring revision procedures. Materials and Methods: A retrospective chart review of rhinoplasty patients from 2002 to 2019 of the primary author (D.M.T.) was performed. The objective of this study is to demonstrate the use of postoperative antibiotic soaks and irrigations in rhinoplasty, as well as evaluate the postoperative infection rates. Results: Of the 3084 rhinoplasty procedures evaluated, there were 19 postoperative infections (infection rate [IR] = 0.62%). Patients without antibiotic soaks or irrigations had 17 infections (IR = 1.01%). The IR of antibiotic soaks was 0.08% with a significant reduction compared with no soaks/irrigations (p = 0.0053). With antibiotic soaks and irrigations, there was 1 infection (IR = 0.49%) with no significant difference between no soaks/irrigations or soaks alone. Conclusions: The use of antibiotic soaks and irrigations resulted in an IR of 0.62%. Antibiotic soaks reduced the rate of postoperative infection, particularly in secondary rhinoplasty. Antibiotic soaks and irrigations are safe, effective, and well-tolerated by patients. As a result, these techniques may be considered in patients undergoing rhinoplasty, particularly those with an extensive revision history, trauma, filler, prior infection, or underlying disease processes.

Distribution of Paycheck Protection Program to otolaryngology practices during the COVID-19 pandemic.

BACKGROUND: The Coronavirus disease of 2019 (COVID-19) has impacted physician practices in many ways with some ENT clinics reporting around a 50% drop in completed scheduled ENT visits during the first wave of the pandemic compared to 2019. AIMS: This study surveyed first round PPP loan disbursement to otolaryngology practices in the United States in response to COVID-19. METHODS: A cross-sectional study was conducted using publicly available data published on PPP by the SBA. Otolaryngology clinics receiving loans greater than $0.15M were filtered using the following terms: "otolaryngology", "otolaryngologist","sinus", "head and neck", "throat", "ENT", and "facial plastic". 481 ENT clinics that received loans greater than $0.15 M from the Paycheck Protection Program (PPP) were identified. Loan amount, business type, geographicregion, owner race, owner gender, and the number of jobs per business were recorded for each clinic. Chi-square analysis was performed to determine significance (P < 0.05) of each characteristic. RESULTS: Loan distribution was significantly different based on jobs reported (P < .001) and business type (P < .001). 100% of loans ranging from $0.15 M to $0.35 M went to micro and small practices whereas 33% of medium-sized practices received loans greater than $1 M. Higher proportions of Subchapter corporations (60.00%) received smaller loans of $0.15 to $0.35 M than Limited Liability Companies (39.13%) and Corporations (51.69%) which generally employ more people. DISCUSSION: Loan distribution was significantly different between businesses based on jobs reported (P < 0.001), with micro/small practices recieving smaller loans than their medium counterparts. All large businesses recived loans in in excess of $2 M. This suggests proportional distribution of loans in accordance with jobs reported. CONCLUSION: This study suggests PPP funding was objectively distributed to ENT clinics based on staff size. LEVEL OF EVIDENCE: Level 4.

Trauma-informed care improves management of paradoxical vocal fold movement patients.

OBJECTIVES: Vocal cord dysfunction (VCD) has been used by clinicians, primarily pulmonologists, to describe a variety of conditions in which the regulation and coordination of vocal fold movements are part of the explanation of cough or difficulty breathing, mainly paradoxical vocal fold motion disorder (PVFM). Prior studies show an intersection of mental health issues, primarily anxiety, and PVFM. We began incorporating mental health screening tools using the Life Events Checklist-5 (LEC-5) and the Posttraumatic Stress Disorder (PTSD) Checklist for Civilians (PCL-C) to assess symptomatology that may be related to traumatic life events. We seek to review the utility of these questionnaires for identifying patients who have experienced emotional trauma and use the principles of trauma-informed care currently lacking for PVFM. METHODS: We incorporated mental health screening tools using the PCL-C and LEC-5 for anyone referred to the Chicago Institute for Voice Care for VCD from the pulmonology clinic at our institution. Each patient underwent a comprehensive strobovideolaryngoscopy including provocative maneuvers to provoke paradoxical movements. RESULTS: A total of 16 subjects were analyzed; of those, seven (43.8%) screened positive for PTSD with the PCL-C. Overall, 58 traumatic events occurred among the 16 patients, with 31 (61.7%) of the traumatic events occurring in the seven positively screened for PTSD. CONCLUSIONS: Using the PCL-C and LEC-5, the principles of trauma-informed care principles were applied to patients initially referred for VCD who were found to have prior traumatic events. We recommend early mental health screening to establish a multidisciplinary team in PVFM. LEVEL OF EVIDENCE: 3 Laryngoscope, 130:1508-1513, 2020.

Common Complications in Rhytidectomy.

Complications of rhytidectomy are well known, yet often preventable. A thorough preoperative history and physical along with realistic patient expectations provide the surgeon and patient with insight into potential complications and postoperative management. Understanding of surgical pitfalls and avoidance are crucial in beginning to manage facelift complications. Possible complications of facelift techniques should not discourage surgeons from pursuing a particular technique as the majority of complications are temporary. Though, a strong patient-physician relationship is critical when complications occur. Complications may be frustrating for both the patient and surgeon, yet are overwhelmingly temporary and manageable without surgical intervention.