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Reply: Work-Related Musculoskeletal Injuries in Plastic Surgeons in the United States, Canada, and Norway

Khansa, Ibrahim M.D.; Khansa, Lara Ph.D.; Westvik, Tormod S. M.D.; Ahmad, Jamil M.D.; Lista, Frank M.D.; Janis, Jeffrey E. M.D.

Plastic and Reconstructive Surgery: November 2018 - Volume 142 - Issue 5 - p 812e-813e
doi: 10.1097/PRS.0000000000004956

Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles, Los Angeles, Calif.

Department of Business Information Technology, Pamplin College of Business, Virginia Tech, Blacksburg, Va.

Division of Plastic Surgery, Telemark Hospital, Skien, Norway

Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada

Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio

Correspondence to Dr. Janis, Department of Plastic Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, Ohio 43212,

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We would like to thank Drs. Ando, Fuse, and Yamamoto for their letter regarding our recently published study entitled “Work-Related Musculoskeletal Injuries in Plastic Surgeons in the United States, Canada, and Norway.”1 In their letter, the authors describe a modified microscope with a screen that allows both the surgeon and the assistant to look forward instead of down while performing microsurgical procedures.

In our study, we found that microsurgery was one of the three plastic surgical procedures most likely to exacerbate musculoskeletal symptoms. We also found that long surgery duration and prolonged neck flexion were two of the three maneuvers most likely to trigger musculoskeletal symptoms. Therefore, the novel idea presented by Drs. Ando, Fuse, and Yamamoto is of great potential benefit, because it allows microsurgeons to avoid prolonged neck flexion. Perhaps even more harmful than neck flexion is forward head posture, which microsurgeons tend to adopt to reach the eyepiece of the microscope, which is usually located over the patient. Forward head posture causes significant strain on the neck: for every inch of forward head positioning, the stress exerted by the head on the neck increases by 10 lb.2

Because the authors use the microscope at various magnifications for the entire surgical procedure, including flap elevation, the camera also obviates the need for surgical loupes, which are thought to contribute to neck pain. Although several studies have failed to demonstrate a significant association between modern lightweight loupes and musculoskeletal symptoms,3,4 the authors’ idea may have great benefit nonetheless.

Some questions regarding this new technology remain: How steep is the learning curve, in terms of hand-eye coordination, for the microsurgeon who is accustomed to operating with a conventional microscope? Does the new system allow the assistant to actively participate in the operation, or does it diminish the operating experience of the trainee? A study evaluating surgical outcomes, operating times, and the experience of both the surgeon and the trainee with the new system would be a welcome addition to both the microsurgery and ergonomics fields.

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Dr. Janis has served as a consultant for LifeCell, Bard, Daiichi Sankyo, Pacira, and Allergan within the last 12 months prior to submission of this article but has no active conflicts of interest, and receives royalties from Thieme Publishing. Drs. Khansa, Westvik, Lista, and Khansa have no relevant financial disclosures. Dr. Ahmad receives royalties from Thieme Publishing.

Ibrahim Khansa, M.D.Division of Plastic and Maxillofacial SurgeryChildren’s Hospital Los AngelesLos Angeles, Calif.

Lara Khansa, Ph.D.Department of Business Information TechnologyPamplin College of BusinessVirginia TechBlacksburg, Va.

Tormod S. Westvik, M.D.Division of Plastic SurgeryTelemark HospitalSkien, Norway

Jamil Ahmad, M.D.Frank Lista, M.D.Division of Plastic and Reconstructive SurgeryUniversity of TorontoToronto, Ontario, Canada

Jeffrey E. Janis, M.D.Department of Plastic SurgeryThe Ohio State University Wexner Medical CenterColumbus, Ohio

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1. Khansa I, Khansa L, Janis JE, et al. Work-related musculoskeletal injuries in plastic surgeons in the United States, Canada, and Norway. Plast Reconstr Surg. 2018;141:165e175e.
2. International Ergonomics Association. What is ergonomics? Available at: Accessed July 19, 2018.
3. Hayes MJ, Osmotherly PG, Taylor JA, Smith DR, Ho A. The effect of loupes on neck pain and disability among dental hygienists. Work 2016;53:755762.
4. Lindegård A, Gustafsson M, Hansson GÅ. Effects of prismatic glasses including optometric correction on head and neck kinematics, perceived exertion and comfort during dental work in the oral cavity: A randomised controlled intervention. Appl Ergon. 2012;43:246253.
Copyright © 2018 by the American Society of Plastic Surgeons