Use of a Surgical Microscope for Subperichondrial-Subperiosteal Dissection in Preservation Rhinoplasty: Ergonomic Considerations.

Preservation of anatomical components in rhinoplasty has gained increasing popularity over recent years. Given that elevation of the soft tissue envelope in a continuous subperiochondrial-subperiosteal dissection preserves soft tissues, vessels, nerves, and lymphatics, this procedure may result in faster healing time and less swelling and scarring. However, the technique requires a learning phase and can be challenging to perform because it typically requires meticulous dissection under surgical loupes. The dissection may thus be time-consuming and a burden for surgeons, especially in secondary rhinoplasty cases. Further, the potential risk of musculoskeletal discomfort and injury to the surgeon should not be overlooked; consideration for surgical ergonomics is needed to prevent injuries and enhance surgical performance. To address these issues, we propose the use of a surgical microscope for subperiochondrial-subperiosteal dissection in preservation rhinoplasty. A microscope enables clear visualization of the surgical field and allows surgeons to make precise and delicate manipulation maneuvers. Moreover, it may also enable surgeons to maintain an ideal ergonomic posture and neutral positioning of their joints, thereby reducing physical strain. A surgical microscope may thus be a useful tool for subperiochondrial-subperiosteal dissection by providing clear visualization of the surgical field and improved surgical ergonomics for surgeons.

Takeaways

Question: The subperichondrial–subperiosteal dissection requires meticulous dissection and can be challenging to perform; the dissection may be time-consuming and a burden for surgeons. Therefore, there is potential risk for musculoskeletal discomfort and injury to surgeons.

Findings: The use of a microscope enables surgeons to take the ideal posture and decreases the load on the neck and body, lowering the risk of muscular discomfort and fatigue.

Meaning: In subperiochondrial–subperiosteal dissection, a surgical microscope may provide surgeons with enhanced surgical ergonomics and clear visualization of the surgical field.

INTRODUCTION

Preservation of anatomical components in rhinoplasty is becoming increasingly common.[1] Elevating the soft tissue envelope in a continuous subperiochondrial–subperiosteal dissection minimizes swelling and scar remodeling, enables near-normal sensation, and avoids long-term thinning of the soft tissue envelope.[2] (See figure, Supplemental Digital Content 1, which demonstrates the postoperative swelling of a patient who underwent tip plasty with septal extension graft. http://links.lww.com/PRSGO/B970.) However, this technique requires a learning phase and can be challenging because it typically requires meticulous dissection under surgical loupes.[3,4] The dissection can thus be time-consuming and a burden especially for less-experienced surgeons. There is also potential risk for musculoskeletal discomfort and injury to surgeons.[5-7] Here, we propose the use of a surgical microscope in subperiochondrial–subperiosteal dissection to provide surgeons with clear visualization of the surgical field and enhanced surgical ergonomics.

SURGICAL PROCEDURES

Between August 2018 and September 2021, we performed subperichondrial–subperiosteal dissection under a surgical microscope in 127 rhinoplasty cases (48 primary cases and 79 secondary). All operations were performed using an open approach under general anesthesia.

Surgery was started under the microscope by making a columellar incision, which was sequentially extended to bilateral infracartilaginous incisions. Preserving the Pitanguy and scroll ligaments, subperichondrial dissection of the lower and upper lateral cartilage (LLC and ULC, respectively) was performed and continued to the subperiosteal dissection. The periosteum was incised and the subperiosteal dissection was initiated under a microscope, and then, the subperiosteal dissection can be continued blindly or under a microscope, as needed. Following the dissection, various steps of rhinoplasty were performed with or without the microscope depending on the circumstances. Along with the instruments for nose surgery, microsurgical instruments such as a Castroviejo needle holder were utilized because they facilitate working effectively under the vision field of a microscope. At the end of the operation, the scroll and Pitanguy ligaments were repaired if they had been transected during the procedures.

We did not encounter any complications related to use of a microscope in any case. Although microscope use prolonged dissection time by 30% in the initial 10 cases compared with dissection under loupes, there was no obvious increase in surgical time after this short learning phase.

DISCUSSION

The meticulous procedures required for complete subperichondrial dissection compared with the traditional subsuperficial musculoaponeurotic system approach demand a learning curve and longer dissection time, especially in patients with weak and hypoplastic LLC, as observed in Asian populations.[1,3,4] As a consequence, surgeons may develop musculoskeletal discomfort and even injury, making surgical ergonomics and a clear magnified surgical view important considerations.[5]

The prevalence of musculoskeletal pain among plastic surgeons is estimated to be as high as 78.3%–94%.[5,8,9] Surgeons who are unaware of ergonomic principles are at greater risk of work-related musculoskeletal discomfort and injury. Musculoskeletal pain in surgeons has downstream consequences, including poor outcomes, lost revenue, and burnout. Optimizing ergonomic practices can prevent injuries and enhance performance, thereby improving the physical health and well-being of surgeons and increasing career longevity.

The ideal posture entails neutral joint positioning and minimal muscular strain: the head should be directly over the shoulders and the chin slightly tucked, with a maximum neck flexion angle of 15–25 degrees.[10-12] The operation can be performed standing or seated depending on the surgeon’s preference. While standing, the shoulders should be directly over the pelvis and the feet spaced hip-width apart. When seated, the feet should rest flat on the ground with the knees flexed at an angle of 90 degrees or greater.[7,13] The height of the operating table should also be appropriately adjusted: the working surface should be up to 10 cm below to 5 cm above elbow height.[14] Surgeons should be careful not to over flex, twist, or laterally flex their back or neck (Fig. 1A).[15]

Fig. 1.

Comparison of poor and good ergonomic postures. A, An example of a common but poor body posture. The neck is extremely flexed and the back twisted and laterally flexed. B, An example of good posture. The head is directly over the shoulders, and the head and neck are in a neutral position. The surgeon’s shoulders are directly over the pelvis, and the feet are hip-width apart.

Surgical microscopes provide users with a clear surgical view; the magnification is easily adjustable and the surgical field is well lit by the light from the microscope.[16] This allows for precise, meticulous, and atraumatic procedures and enhanced ability to preserve the soft tissue envelope. (See Video [online], which demonstrates the subperichondrial dissection under microscope.) Moreover, use of a microscope can offer improved ergonomics to surgeons. The angle and distance of the microscope’s object lens is easily adjustable so as to reduce postural deviations; surgeons can avoid excessively tilting their head when looking into the dissection plane (Fig. 2). Thus, a microscope enables surgeons to maintain a neutral head-neck posture and horizontal gaze while keeping other joints in the ideal neutral position (Fig. 1B).[17]

Video 1.

A microscope provides surgeons with clear visualization of the surgical field and the ability to perform precise and meticulous manipulations.

Fig. 2.

The angle and distance of the microscope’s object lens is easily adjustable, which can reduce postural deviations while working.

Performing meticulous procedures without magnification may require surgeons to adopt an awkward posture, resulting in musculoskeletal fatigue and physical complaints. Improving a surgeon’s view may thus improve ergonomic postures by reducing extensive neck and back flexion and shoulder lifting.[18,19]

Despite offering several advantages, including portability and expense, the use of loupes can require surgeons to over flex or twist their neck, thereby increasing the workload on their muscles. Several studies have reported the ergonomic edge of microscopes over loupes.[16,17,20] Moreover, although use of a surgical headlight is recommended for proper illumination of the surgical field,[3] the weight of the headlight, along with loupes, can increase the load on the neck, leading to the risk of muscular discomfort and fatigue.[6] In contrast, the microscope’s built-in light eliminates the need for a headlight and thus any added strain on the neck and body.

Of course, microscope use can also be a risk factor for work-related musculoskeletal discomfort and injury. A common etiology of such symptoms is the static posture of the neck and upper body while operating under a microscope.[21] Therefore, surgeons should take scheduled breaks during long surgeries to minimize the risk of injury.[7]

Other advantages of using a microscope include enhanced communication with the rest of the team and the education and motivation of residents and nurses by ensuring they are able to observe the surgical site.[15,22] Moreover, high-quality video from the surgeon’s perspective can be recorded without camera shaking, enabling accurate documentation of procedures for surgical education, academic presentations, critical analysis of technical skills, and patient safety.

Major drawbacks of microscope use include higher cost and the need for more space.[15,22] In addition, surgeons who are unfamiliar with using a microscope may have to overcome a learning curve.

In conclusion, we propose that surgical microscopes are a useful tool for preservation rhinoplasty. In addition to providing a clear surgical field and facilitating meticulous procedures, microscopes also enhance surgical ergonomics and reduce musculoskeletal discomfort and injury among surgeons.

ACKNOWLEDGMENTS

The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the study participants, including consent to participate and to publish the findings.