The Current State of Surgical Ergonomics Education in U.S. Surgical Training: A Survey Study.

OBJECTIVE: The aim of this study was to characterize the current state of surgical ergonomics education in the United States. BACKGROUND: The burden of work-related musculoskeletal disorders (MSDs) in surgeons is high and no overarching strategy for redress exists. Twelve distinct specialties describe an unmet need for surgical ergonomics education (SEE). This study aimed to define the current state of SEE in U.S. surgical training programs. METHODS: We performed a descriptive analysis of a 20-item questionnaire of ACGME-certified program directors from 14 surgical and interventional medical specialties. Formal SEE was defined as any organized education module that reviewed the occupation-specific burden of common work-related MSDs and described a framework for prevention via occupation-specific applied ergonomics. Program directors were queried regarding SEE provision, characteristics, and perceived trainee attitude toward the education. RESULTS: Questionnaires were received from 130 of 441 (29.5%) program directors. Two (1.5%) provided formal SEE and 33 (25.4%) provided informal SEE, which consisted of unstructured intraoperative directives and isolated lectures. Two programs previously provided SEE but discontinued the effort due to lack of an evidence-based framework and instructors. Trainees appeared to think that learning surgical ergonomics skills was a worthwhile time investment in 100% and 76.7% of current formal and informal SEE, respectively. CONCLUSION: SEE is rarely provided in any capacity (25.4%), let alone in a consistent or evaluable fashion (1.5%). Impediments to sustainable SEE include lack of an evidence-based framework for education and instructors. An evidence-based, reproducible, and accreditation council-compliant SEE module would be a valuable resource for the surgical and interventional medical communities.

Work-Related Musculoskeletal Disorders among Plastic Surgeons: A Systematic Review.

BACKGROUND: To date, no review has been conducted on the growing body of literature describing various work-related musculoskeletal disorders (MSDs), ergonomic hazards, and potential interventions relevant to plastic surgeons. This systematic review sought to (1) define the scope of coverage of this important issue in the peer-reviewed literature; (2) critically assess the evidence; and (3) provide recommendations for future directions. METHODS: We conducted a literature search of MEDLINE, Embase, Web of Science, and PubMed from the inception of each database until 2016. All articles reporting on work-related MSDs or ergonomics among plastic surgeons were reviewed, summarized, and assessed for trends. RESULTS: Sixteen articles met our inclusion criteria including five expert opinions, four cross-sectional studies and case reports/series, one review, and six experimental studies. Four articles presented evidence on disease burden. The most commonly described work-related MSD was cervical spine disease, for which one study reported a career prevalence of 24.7% (point prevalence in the general population: 0.1-0.4%); three studies reported 64 cases of surgeon work-related MSD resulting in surgical intervention, decreased productivity, or involuntary early retirement. Eight studies described interventions, most of which aimed to improve the ergonomics of microsurgery. CONCLUSION: This review found low-level evidence of plastic surgeons' vulnerability to a work-related MSD at times severe enough to end careers. Further investigation is needed to clearly define this important problem in plastic surgery. Specifically, future directions should include more methodologically rigorous epidemiologic studies evaluating disease burden.

Relevant Surgical Anatomy of Pterygomaxillary Dysjunction in Le Fort III Osteotomy.

BACKGROUND: Le Fort III osteotomy represents the foundation of surgical correction for midface hypoplasia. One serious complication of Le Fort III osteotomy is severing the internal maxillary artery or its branches during osteotome advancement for pterygomaxillary dysjunction. This study sought to characterize the relevant surgical anatomy of the infratemporal fossa and of the internal maxillary artery as it enters the pterygomaxillary fissure. METHODS: Bilateral midface dissections were performed on 15 fresh, normocephalic adult cadavers (30 hemifaces). Four superficial anatomical measurements were performed on the surface of the face, followed by 10 deep measurements of the internal maxillary artery and its branches relative to the infratemporal fossa and its surrounding bony landmarks. RESULTS: The distance from the anterosuperior aspect of the zygomatic arch to the sphenopalatine artery entering the pterygomaxillary fissure was 38.9 ± 3.2 mm. The distance from the alveolar process of the maxillary bone to the sphenopalatine artery entry into the pterygomaxillary fissure was 30.3 ± 6.4 mm. The zygomaticofrontal suture was 43.4 ± 8.5 mm from the sphenopalatine artery entry into the pterygomaxillary fissure, 58.8 ± 8.0 mm from the pterygomaxillary junction, and 74.9 ± 6.5 mm from the maxillary alveolar process. The distance from the sphenopalatine artery to the posterior superior alveolar artery was 14.4 ± 4.1 mm. Elevation of the internal maxillary artery from the lateral pterygoid plate was 5.8 ± 2.5 mm. CONCLUSION: This study characterizes the surgical anatomy of the infratemporal fossa in the context of Le Fort III osteotomies and their associated pterygomaxillary dysjunctions.

Novel techniques for the surgical management of abdominopelvic constriction rings in amniotic band syndrome.

Constriction rings are associated with amniotic band syndrome and most often present in the extremities. Constriction bands of the trunk are rare, and a standard of surgical care remains elusive. Traditional methods of constriction ring excision rely on soft-tissue rearrangement with multiple Z-plasties, but renewed interest in linear closure and limited Z-plasty has emerged. The authors review contemporary literature and report two cases of abdominopelvic constriction ring reconstruction with long-term follow-up. Novel techniques including anterior sheath Y-V plasty, pteruges release of the Scarpa fascia, and limited Z-plasty closure may minimize the need for serrated scar patterns.

Scalp reconstruction with inverted myocutaneous latissimus free flap and unmeshed skin graft.

Limited skin paddle size, peripheral thinning, or lack of cerebral expansion after radiotherapy may necessitate secondary sculpting after latissimus free flap reconstruction of large scalp defects. This series presents a novel modification of the myocutaneous latissimus dorsi free flap for use in large scalp defects. After superficial artery isolation, titanium mesh is placed into the calvarial defect to recapitulate the inner table. The myocutaneous latissimus flap is harvested in standard fashion, deepithelialized, and inverted. The skin paddle is placed over titanium mesh to fill the calvarial defect, then sewn over a drain. The inverted latissimus muscle is draped over the defect and extended peripherally beneath the pericranium. The flap is sewn to the scalp internally using a vest-over-pants suture pattern, and the thoracodorsal and superficial temporal vessels are anastomosed and left facing outward. Unmeshed skin graft is draped over the muscle and vessels then sutured loosely. Patients with complex scalp defects whose soft tissue defect exceeded the size of latissimus skin paddle available with primary closure were considered eligible for inverted latissimus free flap reconstruction. Follow-up range was 6 months to 12 months. Over a 2-year period, five patients underwent inverted latissimus free flap reconstruction. Scalp defects ranged in size from 10 × 8 cm to 17 × 11 cm. The calvarial defect was smaller than the soft tissue defect in all cases. All flap donor sites were closed primarily. All five flaps took, and donor site outcomes were acceptable. Aesthetic outcomes were satisfactory with well-contoured, calvarial-shaped results. Cosmesis was most notably limited by skin graft joint lines. No patients underwent secondary surgical revision. The inverted myocutaneous latissimus free flap is a safe and effective method for reconstructing large or irradiated scalp defects.

Occupational injury in plastic surgeons.

BACKGROUND: Little research to date has investigated musculoskeletal injury in the surgical workforce. This study estimates the prevalence and functional impact of work-related injury in plastic surgeons and other surgical specialists. METHODS: A validated self-assessment of work-related injury was administered to surgeons at various professional conferences, over the telephone, and via email. Prevalence rates for each injury were tabulated, and a regression analysis was conducted to identify potential associations between demographic risk factors and self-reported injury. RESULTS: Of 500 surveys administered, 339 (67.8 percent) were returned. Musculoskeletal symptoms were observed in 81.5 percent of surveyed surgeons. Of 17 injuries of interest, the most prevalent conditions were muscle strain, vision changes, cervical pain, lumbar pain, and shoulder arthritis/bursitis. Carpal tunnel syndrome and epicondylitis were reported by 15.1 and 13.5 percent of respondents, respectively, more than three times general population prevalence rates. Years in practice were associated with carpal tunnel syndrome. Microscope usage of 3 hours or more per week was associated with cervical and thoracic pain. Hand surgeons appeared to be more prone to thumb arthritis than other specialties. CONCLUSIONS: Self-reported injury is more prevalent in surgery than in previously described, labor-intensive populations. Sampled surgeons appear younger than the general surgery workforce, and as a result, this study may underestimate the prevalence of occupational injury, particularly carpal tunnel syndrome. This study underscores the need for a formal, multicenter assessment of occupational injury in surgeons.