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Background: Surgeons are at risk for musculoskeletal disorders from ergonomic strain in the operating room. These deficits may stem from neuromuscular control deficits. Neuromuscular activation exercises (NMEs) may strengthen the brain-muscle connection. This study aimed to assess the utility of a surgeon-oriented NME protocol on posture., Methods: Surgeons, operating room staff, and medical students completed a professionally established NME routine. An electronic application, PostureScreen®, assessed participants' posture. A long-term cohort was assessed before and after a 2 to 6-week routine. A short-term cohort was assessed immediately before and after completion. All participants additionally completed a postintervention survey., Results: After intervention, the short-term cohort (n = 47) had significantly reduced frontal and sagittal postural deviation (P < 0.05). A significant decrease in effective head weight was additionally demonstrated with decreased neck flexion and increased cerebral-cervical symmetry (P < 0.05).The long-term cohort (n = 6) showed a significant postintervention decrease in lateral and anterior shoulder translation (P < 0.05). Total anterior translational deviations demonstrated trend-level decrease (P = 0.078). This demonstrates that after intervention, participants' shoulders were more centered with the spine as opposed to shifted right or left. Survey results showed participants favored exercises that immediately brought relief of tension., Conclusions: A decrease in postural deviations associated with NME in both cohorts demonstrates NME as a potential mechanism to protect surgeon musculoskeletal health and improve well-being. Survey results demonstrate areas of refinement for NME protocol design., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Minority representation and promotion in medicine is lacking. Social media can facilitate change by raising awareness of biases, empowering others, and cultivating connections. The TimesUpPRS Instagram account was created in March 2020 to foster diversity, equity, and inclusion (DEI) in plastic surgery by celebrating surgeons of diverse identities and emphasizing the need to create safe, fair, and equitable workplaces. We aim to characterize its content, audience demographics, engagement, and impact., Methods: All TimesUpPRS posts published until March 2022 were reviewed for content analysis. Audience demographics were assessed through Instagram Insights. Engagement was assessed through likes, comments, and posts tagging @TimesUpPRS., Results: Three hundred fifty-five posts have been published, with 45.9% original content. These posts discuss representation or treatment of women (39.7%), Black (24.2%), Asian and Pacific Islander (14.4%), LGBTQ+ (12.7%), LatinX (6.5%), people of color overall (4.8%), first generation-low income (1.7%), and Native American (1.1%) individuals. 45.1% aimed to raise social awareness, 19.4% spotlighted plastic surgery figures, 16.3% highlighted research, and 5.6% advertised opportunities for community involvement. The mean (SE) number of hashtags utilized was 10.9 (0.6), with #ilooklikeasurgeon used most. There were 2052 followers, but 10,025 accounts reached. Of reached accounts, 66.8% were women, 71.8% were from the U.S., and 55% were aged 25 to 34. The mean (SE) number of likes and comments per post was 62.2 (3.4) and 2.6 (0.2). 85.0% of comments were supportive. Three hundred sixty-six posts tagged @TimesUpPRS. TimesUpPRS has also garnered industry and private sponsorship, inspired DEI programming, and collaborated with multiple other organizations., Conclusions: In 2 years, TimesUpPRS has generated 350+ posts and reached 10,000+ accounts. Content highlighted figures of diverse identities and cultivated high, positive engagement. Now with 20 content creators, TimesUpPRS will continue increasing content, expanding its audience, and fostering impactful discussion that helps shift the existing culture to one of inclusivity and equity., (Copyright © 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Historically, breast-conserving surgery may not be pursued when the oncologic deformity is too significant and/or not tolerant of radiotherapy. Reconstruction using recruitment of upper abdominal wall tissue based on the intercostal artery perforating vessels can expand breast conservation therapy indications for cases that would otherwise require mastectomy. This report aims to describe the expanded use of the intercostal artery perforator (ICAP) as well as detail its ease of adoption., Methods: All patients who underwent ICAP flaps for reconstruction of partial mastectomy defects at a single institution were included. Demographic data, intraoperative data, and postoperative outcomes were recorded. Intercostal artery perforator flap outcomes are compared with standard alloplastic reconstruction after mastectomy., Results: Twenty-seven patients received ICAP flaps compared with 27 unilateral tissue expanders (TE). Six cases included nipple-areolar reconstruction, and 6 included skin resurfacing. The average defect size was 217.7 (30.3-557.9) cm 3 . Plastic-specific operative time was significantly longer in the ICAP cohort ( P < 0.01) with no difference in total operative time ( P > 0.05). Length of stay was significantly longer, and major postoperative complications were significantly more common in TE patients ( P < 0.01, P > 0.05). Seven TE patients required outpatient opiate refills (26%) versus 1 ICAP patient (4%) ( P = 0.02). One ICAP patient required additional surgery. Patients reported satisfaction with aesthetic outcomes. Average follow-up in the ICAP cohort was 7 months., Conclusions: Lumpectomy reconstruction using ICAP flaps can effectively expand breast conservation therapy indications in resection of breast skin, nipple-areola, or large volume defects. This technique is adoptable and of limited complexity. Enhancing breast-conserving surgery may improve outcomes compared with mastectomy reconstruction. Intercostal artery perforator patients may require fewer opioids, shorter hospital stays, and lower operative burden., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To identify factors associated with cervical-thoracic spine posture in otolaryngology surgeries and evaluate the efficacy of a commercially available posture-training device in enhancing surgeon ergonomics., Methods: Over 3 months, neck and spine posture from individuals performing otolaryngology surgeries was recorded using UpRight Go 2™. Average baseline posture was first recorded and biofeedback was later introduced to attempt to correct posture. The proportion of time spent in upright/neutral cervical-thoracic spine posture was correlated with surgeon and procedure characteristics and compared to proportion of upright posture time after biofeedback intervention., Results: The proportion of upright operating time was significantly different between procedure subtypes and surgical approaches with best performance in rhinology procedures and worst performance in head and neck surgeries (90% vs. 62%; both p  < .001). Female gender, shorter stature, and use of sitting stools were associated with greater proportion of surgery spent upright (all p  < .05). Loupes use was associated with less time in upright posture ( p  < .001). With biofeedback intervention, 8 of 10 subjects demonstrated an average of 5% improvement in operating upright, with most improvement found when performing laryngology procedures (7%) and least improvement in head and neck procedures (2%)., Conclusions: While surgeon posture varies across otolaryngology surgeries, sitting and minimizing the use of loupes may help promote a more ergonomic operating environment and improve surgeon posture. Although the efficacy of biofeedback intervention from a commercially available posture-training device differs among otolaryngologists, exploration of alternative interventions and incorporation of an ergonomics curriculum is warranted to address postural issues experienced by many surgeons., Level of Evidence: 3., Competing Interests: The authors have no conflicts of interest to disclose., (© 2022 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Background: Plastic surgeons have an increased risk for the development of musculoskeletal disorders because of frequent poor ergonomics of the operating room. This study characterizes selected plastic surgery procedures, with an attempt to identify high-risk procedures and procedural components as well as the impact of biofeedback on surgical ergonomics., Methods: A commercially available posture training device was used to initially record neck and spine positioning and later to send biofeedback to prompt surgeons to correct posture. Device data were correlated with in-person observations to characterize factors associated with more time spent in the slouched/nonneutral cervical and thoracic spine posture., Results: The proportion of time spent in the upright position during surgery was significantly different among male and female participants, level of training, participant height, in the sitting versus nonsitting positioning (P < 0.001), with loupes use, and if there was more than an 8-inch height difference between 2 participants (mean, 0.70 ± 0.285). Using the device intervention, all participants spent a larger proportion of operating time upright. Half of these improvements in posture were statistically significant. While in feedback mode, participants experienced shorter and more frequent periods of slouching/nonneutral posture. When comparing the same participant performing the same procedure with and without device biofeedback, 72.2% of participants spent more time in the upright/neutral posture during the surgery when the device was sending feedback., Conclusions: Biofeedback devices used in the operating room can lead to improved surgical posture, which may translate to reduction of workplace injuries, and overall physician health. This study found that a commercially available posture training device and sitting stools in the operating room could significantly improve physician cervical and thoracic spine posture., Competing Interests: Conflicts of interest and sources of funding: No authors have any relevant conflict of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tissue expander-assisted component separation can be used to increase the amount of skin, muscle, and fascial components available for repair of congenital abdominal wall defects via a staged approach without the need for flap reconstruction. We present the largest case series to date using a tissue expander-assisted component separation technique for treatment of congenital abdominal wall defects in a pediatric patient population., Methods: A retrospective chart review of 9 patients with large congenital abdominal wall defects not initially amenable to primary repair between 2009 and 2020 was performed. Patients first underwent placement of tissue expanders, followed by removal once they had reached a sufficient expander volume. Component separation, with and without mesh placement, was performed to achieve abdominal wall closure., Results: The average age of patients at primary repair was 3.2 years (SD ±1.7 years). Eight patients (88.8%) had congenital omphalocele, and 1 patient (11.1%) had gastroschisis; none were amenable to primary repair. The average size of the defects before closure was 87.6 cm2 (SD = 33.6 cm2). Eighteen tissue expanders were placed in 9 patients, 72.2% of which were placed in the plane between the external and internal oblique muscles. Patients were seen in clinic an average of 6.8 times (SD, ±3.3 visits) for volume expansion into the tissue expander, receiving an average of 32.0 mL in each per visit. An average of 4.3 months (SD, ±1.8 months) elapsed between placement and removal of the expanders. At the time of tissue expander removal and abdominal wall closure, the defects ranged from 30 to 132 cm2 (mean, 54 cm2). All defects were successfully repaired using a component separation and bilateral fasciocutaneous flap advancement. Two patients (18.2%) experienced infection of the surgical site and seroma, both of which required debridement. One patient (9.1%) experienced partial thickness skin necrosis that was managed nonsurgically. The overall complication rate was 36.4%., Conclusions: Omphalocele and gastroschisis can produce abdominal wall defects that are not amenable to primary repair. Staged reconstruction using tissue expander-assisted component separation is a safe and effective method of obtaining adequate local soft tissue to achieve primary closure., Competing Interests: Conflicts of interest and sources of funding: No authors have any relevant conflict of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice., Primary Aim: To provide a qualitative systematic review analysis of long-term outcomes after PABG., Materials and Methods: A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings., Results: After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice., Conclusion: The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.

Background: Medical students receive limited exposure to the field of plastic surgery because most students will not rotate in plastic surgery, especially those at schools without dedicated plastic surgery residency programs. This study aimed to create and validate a plastic surgery learning module for medical students to dispel media-propagated myths and misrepresentation of the breadth of plastic surgery and equip students with referral-making capabilities., Methods: The plastic surgery learning module was created using Articulate Storyline 360 (New York, N.Y.). Student participants were recruited from a single medical school across all four classes. Pre- and postmodule surveys were administered via Qualtrics (Provo, Utah). Scores were computed for the general surgical knowledge section and for each specialty referral question., Results: Twelve students completed usability testing and edits were subsequently made to optimize the module. The module took on average 66 minutes to complete. Sixty-five students (19 MS1, 16 MS2, 15 MS3, 15 MS4) completed efficacy testing. In the premodule survey, students were nearly 100% accurate in identifying breast-related referrals, unlike pediatric/craniofacial (avg: 68%), reconstruction/microsurgery (avg: 64%), and hand/upper extremity (avg: 30%) referrals. Students of all classes exhibited significant improvement in all testing categories except for the breast category, with the most improvement in the hand referrals category. Prior exposure to plastic surgery (57%) correlated with higher premodule hand ( P = 0.003) and breast/cosmetic ( P = 0.01) referral scores., Conclusion: The plastic surgery learning module shows promise to be a comprehensive yet affordable and time-efficient tool for medical students to learn about basic surgical principles and the scope of plastic surgery., Competing Interests: Disclosure: The authors have no financial disclosures or conflicts of interest. This study received funding from the American Council of Academic Plastic Surgeons/Plastic Surgery Foundation., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Unilateral coronal craniosynostosis (UCS) is the third most prevalent form of craniosynostosis. Traditional treatment of UCS has been achieved with fronto-orbital advancement and cranial vault remodeling (FOAR), but utilization of cranial distraction osteogenesis (DO) techniques has increased. This study aims to compare perioperative complications and reoperation trends in FOAR versus DO techniques at a single institution., Methods: An Institutional Review Board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Patients were those that have undergone FOAR or DO with an anterior rotational flap technique as previously described. Indications for secondary procedures included: contour deformities, relapse, surgical site infection, and persistent cranial defects., Results: Eighty-one patients with UCS were identified, 64 patients underwent FOAR and 17 patients underwent DO. When perioperative characteristics were compared, patients who underwent DO were younger in age, however, there was no significant difference in transfusion requirement or length of stay between patient cohorts. Surgery time was increased in DO patients. When perioperative complications were compared, more intraoperative dural tears were observed in the FOAR cohort. When unplanned reoperation rates were compared, patients who had undergone FOAR had a statistically significant higher reoperation rates at 5 years of follow up. When including routine distractor removal as a reoperation, reoperative rate was increased in the DO cohort. No difference in reoperation rates was noted at 5 years following index operation., Conclusions: The safety profile of DO is similar to that of traditional FOAR techniques for treatment of UCS. Longer-term follow-up studies are needed to elucidate whether outcomes are durable, but the unplanned reoperation rate in DO is less than that of FOAR at 5 years and presents several advantages that warrants its use in patients with UCS., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

This article serves as a practical guide for plastic surgeons focusing on repair of primary cleft lip and nasal deformity. We discuss the key anatomic disruption present in cleft lip and nasal deformity and the goals of primary repair. In addition, our preferred surgical technique for unilateral and bilateral cleft lip and nasal deformity is summarized along with technical pearls and pitfalls., Competing Interests: Disclosure: All the authors have no financial interest to declare in relation to the content of this article., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Introduction: The craniofacial asymmetry seen in unilateral lambdoid craniosynostosis may not be effectively treated by posterior cranial vault remodeling, endoscopic suturectomy, and helmet therapy, or suturectomy and distraction osteogenesis alone due to limitations in soft-tissue envelope expansion and relapse of the deformity. The authors report a series of unilateral lambdoid craniosynostosis patients treated with a posterior rotational cranial-flap technique using internal distraction osteogenesis., Methods: Posterior cranial vault reconstruction combined with internal distraction was used, aided by preoperative virtual surgical planning. An in situ posterior rotational flap osteotomy was utilized to maximize dural preservation. Primary outcome measures included age-adjusted volume change and age-adjusted percent volume change per mm distraction. Distraction characteristics and perioperative characteristics were also assessed., Results: A total of 5 patients were identified. Mean predistraction intracranial volume was 1087.5 cc (SD  = 202.3 cc) and mean postdistraction included intracranial volume was 1266.1cc (SD  = 131.8cc). Mean age-adjusted percent included intracranial volume change was 14.1% (SD  = 9.6%), and mean percent intracranial volume change per mm distraction was 0.43%/mm distraction (SD  = 0.37%/mm distraction). One patient developed a distractor site infection postoperatively that was treated successfully with oral antibiotics. All patients had a Whitaker score of 1 at one year follow up., Conclusions: Posterior cranial vault remodeling using osteogenesis and a rotational cranial flap technique with dural preservation can be effectively used to maximize bone flap viability and limit postoperative relapse in patients with unilateral lambdoid craniosynostosis. Long term analysis as well as comparison to open techniques will need to be interrogated., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Introduction: The primary outcome metric in patients with craniosynostosis are changes in intracranial volumes (ICVs). In patients who undergo distraction osteogenesis (DO) to treat craniosynostosis, changes are also dependent on the length of distraction. Virtual surgical planning (VSP) has been used to predict anticipated changes in ICV during cranial vault reconstruction. The purpose of this study is to analyze the actual versus predicted ICV changes using VSP in patients who undergo DO for craniosynostosis management., Methods: All patients with craniosynostosis treated with DO at a single institution, Rady Children's Hospital, between December 2013 and May 2019 were identified. Inclusion criteria are as follows: VSP planning with predicted postoperative ICV values and preoperative and postdistraction CT scans to quantify ICV. Postoperative ICV and VSP-estimated ICV were adjusted for age-related ICV growth. The primary outcome measure calculated was age-adjusted percent volume change per millimeter distraction (PVCPD), and results were analyzed using paired Wilcoxon signed rank tests., Results: Twenty-seven patients underwent DO for cranial vault remodeling. Nineteen patients were nonsyndromic, and 8 patients were syndromic. The median postoperative PVCPD was 0.30%/mm, and the median VSP-estimated PVCPD was 0.36% per millimeter (P < 0.001). A subanalysis of nonsyndromic patients showed a median postoperative PVCPD of 0.29%/mm in nonsyndromic patients that differed significantly from the VSP estimate of 0.34%/mm (P = 0.003). There was also a significant difference in syndromic patients' observed PVCPD of 0.41%/mm versus VSP estimate of 0.79%/mm (P = 0.012)., Conclusions: Virtual surgical planning overestimates the change in ICV attributable to DO in both syndromic and nonsyndromic patients., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Lately, vitamin D has been linked with metabolic and immunological processes, which established its role as an essential component of human health preservation. Vitamin D has been defined as natural immune modulators, and upon activation of its receptors (VDRs), it regulates calcium metabolism, cellular growth, proliferation and apoptosis, and other immunological functions. Epidemiological data underline a strong correlation between poor vitamin D status and higher risk for chronic inflammatory illnesses of various etiologies, including autoimmune diseases. Epidemiological, genetic, and basic studies indicated a potential role of vitamin D in the pathogenesis of certain systemic and organ-specific autoimmune diseases. These studies demonstrate correlation between low vitamin D and prevalence of diseases. In addition, VDRs' polymorphisms observed in some of these autoimmune diseases may further support a plausible pathogenic link. Notably, for some autoimmune disease, no correlation with vitamin D levels could be confirmed. Thus, in the current review we present the body of evidence regarding the plausible roles of vitamin D and VDR's polymorphism in the pathogenesis of autoimmunity. We summarize the data regarding systemic (i.e., systemic lupus erythematosus, rheumatoid arthritis, etc.) and organ-specific (i.e., multiple sclerosis, diabetes mellitus, primary biliary cirrhosis, etc.) autoimmune diseases, in which low level of vitamin D was found comparing to healthy subjects. In addition, we discuss the correlations between vitamin D levels and clinical manifestations and/or activity of diseases. In this context, we address the rational for vitamin D supplementation in patients suffering from autoimmune diseases. Further studies addressing the mechanisms by which vitamin D affects autoimmunity and the proper supplementation required are needed.

This review deals with natural selection operating on heterozygotes as a key factor controlling (a) the frequency of immunodeficiencies, and (b) promoter polymorphism in MHC class II genes. The known difference in frequency distribution of X-linked and autosomal deficiencies lend support to this possibility, and suggest that the frequency of neonatal defect may rise as old-established equlibria between entry and exit of deleterious mutations change. MHC class II gene promoters differ in their capacity to favor Th1 (or reciprocally Th2) responses, thus suggesting that promoter polymorphism is sustained by the greater flexibility in response that this confers on heterozygotes.

Communication barriers erected by grieving children delay problem resolution. Use of the expressive arts--music, art, and body movement--in symbolic communication helps them to express overwhelming feelings and cope with trauma and stress.

A survey was conducted to determine dietitians' attitudes toward and readiness for advocacy. Representative members of an affiliated state dietetic association expressed positive attitudes toward the professional's assumption of the advocate role. The respondents looked to the national, state, and local dietetic associations to provide leadership in the area of advocacy.