We read with great interest the article entitled “Work-Related Musculoskeletal Injuries in Plastic Surgeons in the United States, Canada, and Norway” by Khansa et al.1 Their work is of clinical significance because they elucidated that plastic surgeons often suffer from musculoskeletal symptoms caused by statistic postures during microsurgery. Since microsurgery was introduced, various operations using the microscope have been performed in plastic surgical fields.2 In ordinary situations, a microscope has been used only for microvessel anastomosis or microdissection. Mendez et al. reported the efficacy of use of the heads-up three-dimensional microscope for anastomosis of small vessels in rats, in comfortable postures.3 In this study, we applied a novel heads-up three-dimensional microscope, with a wide variety of magnifications, to flap elevation, with a favorable advantage.
A three-dimensional microscope (KestrelView II; Mitaka Kohki Co., Tokyo, Japan) was set over the surgical field at 300- to 1000-mm working distance. During flap elevation, the surgeon performed the operation while watching the monitor. In accordance with the surgical process, the angle of the camera was adjusted and the magnification was 2× to 5× mainly. The assistant surgeons also watched the same video on the screen set at the opposite side, which enabled them to share the principal surgeon’s view and discuss the surgical procedure (Fig. 1). All of the surgeons were able to see the original surgical field by just looking down. The whole operative video was recorded.
Musculoskeletal injuries are common among plastic surgeons.1,4 By using this intraoperative three-dimensional imaging system, surgeons can share the operator’s original view, which enables them to discuss the operation while watching the same video simultaneously. The camera is set at adequate distance for working, so surgeons can perform the surgical procedure without any trouble, in a comfortable posture. In addition, because of its wide range of magnification, the entire operation can be performed under this microscope—from skin incision to vessel anastomosis. Under higher magnification, we can observe tiny anatomy and perform meticulous dissection. Also, operators can compare the microscopic view and the surgical field by just looking down. In ordinary situations, the assistant operator stands at the opposite side of the main surgeon, so they cannot share the main surgeon’s original view: they watch the 180-degree opposite view. However, using this heads-up three-dimensional microscope, all of the surgeons can get the same view. Furthermore, surgical video can be recorded, so this is very useful for review and education. Because this is the first report of the microscope’s application in reconstructive microsurgery, further investigations are required to confirm the efficacy of the microscope.
The authors have no financial interest to declare in relation to the content of this communication. There were no sources of support for this work.
Yukari Ando, M.D.
Yuma Fuse, M.D.
Takumi Yamamoto, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
National Center for Global Health and Medicine
1. Khansa I, Khansa L, Westvik TS, et al. Work-related musculoskeletal injuries in plastic surgeons in the United States, Canada, and Norway. Plast Reconstr Surg. 2018;141:165e175e.
2. Sommerlad BC. The use of the operating microscope for cleft palate repair and pharyngoplasty. Plast Reconstr Surg. 2003;112:15401541.
3. Mendez BM, Chiodo MV, Vandevender D, Patel PA. Heads-up 3D microscopy: An ergonomic and educational approach to microsurgery. Plast Reconstr Surg Glob Open 2016;4:e717.
4. Capone AC, Parikh PM, Gatti ME, Davidson BJ, Davison SP. Occupational injury in plastic surgeons. Plast Reconstr Surg. 2010;125:15551561.