How to attract our future? - Perception of plastic surgery among medical students

BACKGROUND

There is a mounting body of evidence that underscores the worldwide and US national need for increased plastic surgery recruitment of trainees. Thus, plastic surgery must attract more applicants while maintaining the high-level qualifications of residency candidates.

METHODS

A total of 250 (w = 197) medical students rated the prototypical plastic surgeon (PS), general practitioner (GP), and craniomaxillofacial surgeon (CMF) with respect to traits derived from a literature review on the general perception of surgery, favorability, and their intention to pursue a respective career.

RESULTS

Factor analysis yielded two overarching dimensions of prototype perception in addition to femininity and resilience, one reflecting a coldhearted, narcissistic, competitive character (status primacy; SP), and one reflecting role-model-like traits (hard-working, healthy, admired, and empathetic). Prototypical PSs scored significantly higher on SP than GPs (t(249) = 18.72, p < 0.001, d = 1.26) and CMFs (t(249) = 5.73, p < 0.001, d = 0.36), while receiving significantly less positive evaluations (GP: t(249) = -9.93, p < 0.001, d = -0.63; CMF: t(249) = -3.52, p < 0.001, d = -0.22). The higher participants rated PSs on SP, the more likely a career in plastic surgery was excluded (OR = 0.71, p = 0.03). An opposite relationship with femininity approached significance (OR = 1.32, p = 0.06).

CONCLUSIONS

Given the growing need for PSs, worldwide and US national task fields have to overcome the outdated traits and highlight the field's pro-bono engagement. Furthermore, plastic surgery should further expand its leading role in promoting female trainees.

Full facial retransplantation in a female patient-Technical, immunologic, and clinical considerations

There is limited experience with facial retransplantation (fRT). We report on the management of facial retransplantation in a facial vascularized composite allotransplant recipient following irreversible allograft loss 88 months after the first transplant. Chronic antibody-mediated rejection and recurrent cellular rejection resulted in a deteriorated first allograft and the patient underwent retransplantation. We summarize the events between the two transplantations, focusing on the final rejection episode. We describe the surgical technique of facial retransplantation, the immunological and psychosocial management, and the 6-month postoperative outcomes. Removal of the old allograft and inset of the new transplant were done in one operation. The donor and recipient were a good immunological match. The procedure was technically complex, requiring more proximal arterial anastomoses and an interposition vein graft. During the first and second transplantation, the facial nerve was coapted at the level of the branches. There was no hyperacute rejection in the immediate postoperative phase. Outcomes 6 months postoperatively are promising. We provide proof-of-concept that facial retransplantation is a viable option for patients who suffer irreversible facial vascularized composite allograft loss.

Long-term Outcomes After Facial Allotransplantation: Systematic Review of the Literature

BACKGROUND

Facial vascularized composite allotransplantation (fVCA) represents a reconstructive approach that enables superior improvements in functional and esthetic restoration compared with conventional craniomaxillofacial reconstruction. Outcome reports of fVCA are usually limited to short-term follow-up or single-center experiences. We merge scientific literature on reported long-term outcome data to better define the risks and benefits of fVCA.

METHODS

We conducted a systematic review of PubMed/MEDLINE databases in accordance with PRISMA guidelines. English full-text articles providing data on at least 1 unique fVCA patient, with ≥3 years follow-up, were included.

RESULTS

The search yielded 1812 articles, of which 28 were ultimately included. We retrieved data on 23 fVCA patients with mean follow-up of 5.3 years. More than half of the patients showed improved quality of life, eating, speech, and motor and sensory function following fVCA. On average, the patients had 1 acute cell-mediated rejection and infectious episode per year. The incidence rates of acute rejection and infectious complications were high within first-year posttransplant but declined thereafter. Sixty-five percent of the patients developed at least 1 neoplastic or metabolic complication after transplantation. Chronic vascular rejection was confirmed in 2 patients, leading to allograft loss after 8 and 9 years. Two patient deaths occurred 3.5 and 10.5 years after transplant due to suicide and lung cancer, respectively.

CONCLUSIONS

Allograft functionality and improvements in quality of life suggest a positive risk-benefit ratio for fVCA. Recurrent acute rejection episodes, chronic rejection, immunosuppression-related complications, and heterogeneity in outcome reporting present ongoing challenges in this field.

Comparison of Acellular Solutions for Ex-situ Perfusion of Amputated Limbs

INTRODUCTION

Hypothermic ex-situ machine perfusion (MP) has been shown to be a promising alternative to static cold storage (SCS) for preservation of solid organs for transplantation and vascularized composite allotransplantation. Perfusion with blood-based perfusion solutions in austere environments is problematic due to their need for appropriate storage and short shelf life, making it impractical for military and emergency use. Acellular perfusion has been shown to be effective, but the ideal perfusate solution for MP of amputated limbs is yet to be determined. The purpose of this study is to evaluate the efficacy of alternative perfusate solutions, such as dextran-enriched Phoxilium, Steen, and Phoxilium in ex-vivo hypothermic MP of amputated limbs in a porcine model.

MATERIALS AND METHODS

Amputated forelimbs from Yorkshire pigs (n = 8) were preserved either in SCS (n = 2) at 4°C for 12 hours or machine-perfused at 10°C for 12 hours with oxygenated perfusion solutions (n = 6) at a constant flow rate. The perfusates used include modified Steen-solution, Phoxilium (PHOX), or Phoxilium enriched with dextran-40 (PHODEX). The perfusate was exchanged after 1 and 6 hours of perfusion. Machine data were recorded continuously. Perfusate samples for clinical chemistry, blood gas analysis, and muscle biopsies were procured at specific timepoints and subsequently analyzed. In this semi in-vivo study, limb replantation has not been performed.

RESULTS

After amputation, every limb was successfully transferred and connected to our perfusion device. The mean total ischemia time was 77.5 ± 5.24 minutes. The temperature of the perfusion solution was maintained at 10.18 ± 2.01°C, and perfusion pressure at 24.48 ± 10.72 mmHg. Limb weight increased by 3% in the SCS group, 36% in the PHODEX group, 25% in the Steen group, and 58% in the PHOX group after 12 hours. This increase was significant in the PHOX group compared with the SCS group. All perfusion groups showed a pressure increase of 10.99 mmHg over time due to edema. The levels of HIF-1a decreased over time in all groups except the Steen and the PHODEX group. The biomarkers of muscle injury in the perfusate samples, such as creatine kinase and lactate-dehydrogenase, showed a significant difference between groups, with highest values in the PHODEX group. No significant differences were found in the results of the blood gas analysis.

CONCLUSION

With the exception of significantly higher levels of creatine kinase and lactate dehydrogenase, MP with dextran-enriched Phoxilium provides similar results as that of the commercially available perfusates such as Steen, without the need for cold storage, and at circa 5% of the cost of the Steen solution. Further large-scale replantation studies are necessary to evaluate the efficacy of dextran-enriched Phoxilium as an alternate perfusate solution.

Mucosa and Rejection in Facial Vascularized Composite Allotransplantation: A Systematic Review

BACKGROUND

Facial vascularized composite allotransplantation (fVCA) presents an established approach to restore form and function of patients with catastrophic facial defects. Skin is one of the target tissues of the rejection process, and due to its easy accessibility has become the gold standard in the diagnosis of rejection. Mucosal rejection frequently occurs; however, the added value of mucosal rejection assessment for patient management is unknown.

METHODS

We conducted a systematic review of manuscripts listed in the MEDLINE/PubMed and GoogleScholar databases to identify articles that provide data on mucosal rejection following fVCA. For inclusion, papers had to be available as full-text and written in English. Non-VCA studies and animal studies were excluded. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

We included 17 articles that described changes in allotransplanted mucosa of fVCAs. These articles yielded data on 168 BANFF graded biopsies of corresponding skin and mucosa biopsies. Rejection grades were consistently higher in mucosal biopsies. Concordance between allograft skin and mucosa biopsy grades increased with an increasing skin-BANFF grade. Mucosa rejection grades were on average lower in the early stages of the posttransplant period (<postoperative mo 12, time of motor, and sensory recovery) when compared to the later stages (>postoperative mo 12).

CONCLUSIONS

The mucosa of facial allotransplants is one of the primary targets of rejection. The data indicates that higher-grade skin rejection does not occur in absence of mucosal rejection. Further investigations are needed to elucidate the exact role of mucosal biopsies for fVCA patient management.

Local immunosuppression in vascularized composite allotransplantation (VCA): A systematic review

BACKGROUND

Local immunosuppression in vascularized composite allotransplantation (VCA) aims to minimize immunosuppressant-related toxic and malignant side effects. Promising allograft survival data have been published by multiple workgroups. In this systematic review, we examine preclinical animal studies that investigated local immunosuppression in VCA.

MATERIAL AND METHODS

We conducted a systematic review of manuscripts listed in the MEDLINE and PubMed database concerning preclinical VCA models. Papers included had to be available as full-text and written in English. Non-VCA studies, human trials, and studies using cell-based therapy strategies were excluded. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Literature research retrieved 980 articles. Ten studies published between 2010 and 2019 met the inclusion and exclusion criteria. Seven out of ten articles demonstrated a significant prolongation of allograft survival by using local immunosuppression. Five articles employed tacrolimus (TAC) as the main immunosuppressive agent. Seven studies performed hind-limb VCA in a rat model.

CONCLUSION

The easily accessible location of skin containing VCAs makes it an ideal candidate for local immunosuppression. Published preclinical data are very promising in terms of improved allograft survival and reduced systemic toxicity.

Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients

BACKGROUND

Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage.

METHODS

By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort.

RESULTS

We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001).

CONCLUSION

Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.

Accelerated chronic skin changes without allograft vasculopathy: A 10-year outcome report after face transplantation

BACKGROUND

Long-term outcomes after face transplantation are rarely reported in the scientific literature. Here we present outcome data of a partial face allograft recipient 10 years after transplantation.

METHODS

Medical records were reviewed for functional and psychosocial outcomes as well as complications. Histopathologic analyses of autopsy tissues and characterization of skin immune cells were performed.

RESULTS

The patient retained long-term motor and sensory function, though with a noticeable drop in sensory function after year 5. Social reintegration of the patient was marked by reconnection with his family and participation in public social activities. Immunosuppressive therapy consisted of tacrolimus (target levels 6-8 ng/mL after the first year), mycophenolate, and prednisone, while steroids were completely weaned between years 1 and 7. One acute cellular rejection episode of grade II or higher occurred on average per year and led to chronic skin changes (papillary dermal sclerosis with superficial hyalinization, epidermal thinning with loss of rete ridges, perieccrine fibrosis), but the allograft vessels, muscles, adipose tissue, and bone were spared. Allograft skin was characterized by increased number of CD4+ TNF-α/IL17A producing T-cells as compared with native skin. Long-term kidney function was maintained at 60 mL/min estimated glomerular filtration rate. Unfortunately, the preexisting hepatitis C virus infection with liver cirrhosis was resistant to 3 treatments with new direct-acting antivirals and eventually hepatocellular carcinoma developed, causing the patient's death 10 years after transplantation.

CONCLUSION

This report suggests that face transplants can maintain their function for at least 10 years. Chronic skin changes can occur independently of allograft vasculopathy.

MMP3 Is a Non-invasive Biomarker of Rejection in Skin-Bearing Vascularized Composite Allotransplantation: A Multicenter Validation Study

Background: There is unmet need for non-invasive immunomonitoring to improve diagnosis and treatment of acute rejection in vascularized composite allotransplantation (VCA). Circulating matrix metalloproteinase 3 (MMP3) was described as a candidate non-invasive biomarker to predict treatment response to acute rejection in clinical VCA. However, larger validation studies are yet to be reported to allow for more definitive conclusions.

Methods: We retrospectively measured MMP3 levels using ELISA in a total of 140 longitudinal serum samples from six internal and three external face transplant recipients, as well as three internal and seven external upper extremity transplant recipients. The control groups comprised serum samples from 36 kidney transplant recipients, 14 healthy controls, and 38 patients with autoimmune skin disease. A linear mixed model was used to study the effect of rejection state (pre-transplant, no-rejection, non-severe rejection (NSR), and severe rejection) on MMP3 levels.

Results: In VCA, MMP3 levels increased significantly (p < 0.001) between pre- and post-transplant no-rejection states. A further increase occurred during severe rejection (p < 0.001), while there was no difference in MMP3 levels between non-severe and no-rejection episodes. A threshold of 5-fold increase from pre-transplant levels could discriminate severe from NSR with 76% sensitivity and 81% specificity (AUC = 0.79, 95% CI = 0.65–0.92, p < 0.001). In kidney transplantation, the MMP3 levels were significantly (p < 0.001) elevated during antibody-mediated rejection but not during T-cell mediated rejection (TCMR) (p = 0.547). MMP3 levels in healthy controls and autoimmune skin disease patients were comparable with either pre-transplant or no-rejection/NSR episodes of VCA patients.

Conclusion: The results of this study suggest that serum MMP3 protein is a promising marker for stratifying patients according to severity of rejection, complementary to biopsy findings.

Early and late-recorded predictors of health-related quality of life of burn patients on long-term follow-up

BACKGROUND

Unintentional and intentional burn injuries vary across age groups, gender, income, and global region. In high-income countries, the trend over the last several years has been a reduction in burn incidence, burn severity, length of hospital stay, and mortality rate. However, there is a lack of data on predictors of the health-related quality of life (HRQoL) of major burn survivors extending beyond a follow-up period of 10 years.

PATIENTS AND METHODS

This single-center cross-sectional study is considering 42 long-term severe burn survivors with deep partial thickness burns and an affected total body surface area (TBSA) of ≥20%. For study eligibility design a minimum follow-up of 10 years was obligatory. Entitled individuals were asked to fill in the generic Short Form 36 (SF-36) questionnaire. The physical (PCS) and mental (MCS) component scores of the SF-36 were used as the primary outcome variables. Putative predictor variables were drawn from medical records. Burn-specific functionality and scar tissue quality were assessed using the Burn Specific Health Scale-Brief (BSHS-B) questionnaire and the Patient and Observer Scar Assessment Scale (POSAS), respectively. Correlation between putative predictor variables and SF-36 norm scores were evaluated by Pearson- and Point-Biserial correlation as well as multivariate linear regression. The SF-36 norm scores were compared to the general German population.

RESULTS

Mean follow-up was 14 (±3) years with a minimum and maximum of 10 and 28 years, respectively. Mean age at the time of the incident was 37 (±17) years. The majority of individuals were male (74%). The mean burn size was 39 (±17) % (TBSA) with 76% of the individuals showing a full thickness burn. SF-36 norm scores were not statistically different from the general population. Statistically significant independent predictor variables of the physical summary score were: age at the time of the injury (-0.381), time since injury (-0.466), length of hospital stay (-0.356), limb amputation (-0.318), unemployment (-0.433), work (0.593), hand function (0.601), body image (0.518), affect (0.355), simple abilities (0.602), burns involving the hands (-0.339) and back (-0.343), POSAS patient- (-0.521) and observer scores (-0.483). In multivariate analysis, work (4.315), the POSAS Score (-2.082) and the age at the time of the incident (-0.242) were statistically significant predictors. Statistically significant independent predictor variables of the mental summary score were: duration of mechanical ventilation (-0.459), hand function (0.415), body image (0.502), sexual activity (0.625), social support (0.542), burns involving the back (-0.315) and affect (0.692). In multivariate analysis, affect (13.844) and the length of mechanical ventilation (-0.115) were statistically significant independent predictor variables.

CONCLUSION

Ten years after the burn incident, the quality of life was on average comparable to the one in the general population. Multiple variables seem to influence the physical and mental long-term outcome. Herein presented data may support in adapting and designing follow-up strategies tailored to a patient's burn-specific circumstances.

Image segmentation-based volume approximation-volume as a factor in the clinical management of osteolytic jaw lesions

OBJECTIVE

Size characterization of osteolytic jaw lesions (OJL), in particular of neoplastic nature, is heterogeneously performed and lacks standardization in the medical literature and clinical practice. An OJL's volume holds promise as a surrogate for treatment response and prognosis. We comparatively evaluate various methods for size characterization of odontogenic OJLs.

METHODS

We retrospectively performed semiautomatic image segmentation of CBCT data sets for volume approximation of neoplastic (51) and non-neoplastic odontogenic OJLs (100). We assessed the three greatest orthogonal diameters and calculated the volume using the cuboid- and ellipsoid-formula. Image segmentation was carried out using ITK-SNAP. Image segmentation-based volume approximation served as reference. Intra- and inter-rater variability were evaluated at hand of Bland-Altman-Analysis and dice similarity coefficient (DSC).

RESULTS

Concerning the intrarater variability, we found the DSC to be highest for image segmentation-based volume approximation, simultaneously showing the tightest limits of agreement and greatest reliability. The cuboid formula showed consistent overestimation of the lesion's volume with a percent mean difference of -52 % (upper and lower limits of agreement +8.57 %  and -112.63%, respectively). In mean, the ellipsoid formula underestimated the lesion's volume by 10.1% (upper and lower limits of agreement +76.8%  and -56.6%, respectively). Inter rater variability was higher for formula-based volume approximation. Volume and multilocularity (p = 0.001) correlate with aggressiveness and growth potential.

CONCLUSIONS

Segmentation-based volume approximation holds great promise for patient individualized treatment planning and clinical management. The data suggest that maximum tumour diameter-based size characterization, especially the cuboid-formula and the maximum diameter alone, should not be recommended.

Clinical evaluation of non-syndromic scaphocephaly surgically corrected with the procedure of total vertex craniectomy

The present investigation constitutes a retrospective evaluation of the outcome in children who received surgical correction of a scaphocephalic phenotype by median total vertex craniectomy. Between September 2009 and September 2015, a total of 35 infants with non-syndromic scaphocephaly were treated according to the same standardized operative technique of total vertex craniectomy by a single surgeon approach. At the time of surgery, the patients were between 3 and 12 months of age, with a median of 5 months. The mean duration of the procedure was 94 min. The duration of postoperative follow-up was a mean of 24 months (range 6-49 months). A total of 34 (97%) patients were successfully treated by total vertex craniectomy and were thus classified as category I according to the Whitaker score. Only one individual was assigned to category IV, necessitating secondary major craniofacial corrective surgery. Aesthetic outcomes were excellent in 34 cases and poor in one case. No major complication occurred. The reoperation rate was 3%. The surgical method we present herein is a wide median craniectomy which can be applied in young individuals with non-syndromic single-suture scaphocephaly.

Sarcomas of the sinonasal tract

BACKGROUND

Sinonasal sarcomas are rare and heterogeneous in nature. Continuously collecting data influencing the prognosis is fundamental for optimizing therapeutic assessment of this highly destructive neoplasm.

METHODS

We conducted a single-institution retrospective cohort study considering 27 patients with sinonasal sarcoma.

RESULTS

The overall survival (OS) rates for 1 year and 5 years were calculated as 74% and 36%, respectively. Extent of the primary tumor (P = .010), nodal spread (P = .009), and age (P = .004) significantly reduced the OS. Disease-free survival (DFS) was significantly reduced by age (P = .003), extent of the primary (P = .006), nodal (P = .004), and hematogenous (P = .048) spread. Multimodal therapy including surgery improved the OS and DFS rates (P < .05).

CONCLUSION

Prognosis is poor due to late disease recognition. However, multimodal therapeutic regimens, including surgery, may improve the outcome.

Volumetric analysis of keratocystic odontogenic tumors and non-neoplastic jaw cysts - Comparison and its clinical relevance

The keratocystic odontogenic tumor (KCOT) is capable of causing vast osseous destruction. Histopathological examination is pivotal for diagnosis. The diagnostic process can sometimes be hindered by tissue inflammation of KCOTs with loss of defining criteria, resulting in misdiagnosis as an odontogenic jaw cyst. We discuss the possible merits of volumetric analysis when facing this particular diagnostic dilemma and for pathophysiological characterization of KCOTs. We included 114 patients, of whom 27 were histopathologically diagnosed with a KCOT and 87 with dentigerous (n = 41) and periapical cyst (n = 46). Semiautomatic segmentation and radiological analysis of preoperative cone beam computed tomography (CBCT) image data was carried out using ITK-SNAP. The mean volumetric extent of KCOTs is significantly higher compared to non-neoplastic odontogenic jaw cysts (p = 0.001). The mean volume and standard deviation for KCOTs and non-neoplastic odontogenic jaw cysts was 10381 mm³ ± 6410 and 5813 mm³ ± 4425, respectively. Volumetric analysis reveals that KCOTs significantly exceed the mean size of non-neoplastic odontogenic jaw cysts, adding an argument in favor of the neoplastic nature of KCOTs. In the case of difficult histopathological examination, lesions with a size exceeding a value of about 3000 mm³ could be considered for close clinico-radiologic follow-up.

Size distribution and clinicoradiological signs of aggressiveness in odontogenic myxoma-three-dimensional analysis and systematic review

OBJECTIVES

Therapeutic assessment of odontogenic myxoma (OM) is poorly standardized. Unidimensional size criteria have shown to be unreliable in therapeutic decision-making. We evaluate the size distribution of OM and scan for associated clinicoradiological signs of aggressiveness. Additionally, we evaluate three-dimensional size delineation of OM aiming to improve future therapeutic assessment of this destructive neoplasm.

METHODS

Primarily, we reviewed the database "PubMed" for data concerning the size of OMs as radiologically determined. Afterwards, the impact of age, sex, locularity and location on the size was investigated by χ² test, Student's t-test and regression analysis. Furthermore, we statistically evaluated the impact of size on the occurrence of clinicoradiological signs of aggressiveness. Secondly, we approximated the volume of five unpublished cases of OM by semi-automatic image segmentation of cone-beam CT images.

RESULTS

Multilocular OMs were significantly larger than unilocular ones (p < 0.002). Age (0.042) and multilocularity (<0.002) significantly impacted size. Size was significantly associated with cortical perforation (0.032) and multilocularity (<0.002), further regression analysis revealed tooth resorption (0.019), cortical perforation (0.005) and multilocularity (<0.002) as significant predictors of size. Employing the volume as a mean of comparison, we found that the biggest OM (38.42 ml; multilocular) was 124 times larger than the smallest (0.31 ml; unilocular). However, using the maximum diameter (cm) as a surrogate for size, the biggest lesion (6.3) was only 5.25 times larger than the smallest (1.2).

CONCLUSIONS

Locularity and volumetric size characterization might help in therapeutic decision-making and could help to improve our understanding of OM.

Improving ergonomics in milking parlors: empirical findings for optimal working heights in five milking parlor types

Milking postures have shifted from seated milking in tethered stalls to milking in a standing position in parlors. However, the musculoskeletal workload of dairy farmers remains high. Previous studies have shown that different working heights affect ergonomics, but they could not objectively evaluate and quantify the workload. The aim of the present study was to assess the effect of working height in different milking parlor types on the milker's workload during the task of attaching milking clusters. Computer-assisted recording and long-term analysis of movements were used to record positions of joints and body regions while performing certain tasks in terms of angular degrees of joints (ADJ) according to the neutral zero method. The 5th, 50th, and 95th percentiles described the distribution of angular degree values measured for each joint. The ADJ were evaluated according to international standards and other scientific literature on the issue to assess the muscular load. The workload was compared between 5 parlor types (auto tandem, herringbone 30°, herringbone 50°, parallel, and rotary) on 15 farms with 2 subjects per parlor and 1 milking period per subject. The working height was defined as a coefficient based on the milker's body height, the floor level, and the cow's udder height. The data recorded during the attachment task were analyzed using generalized linear mixed-effects models taking into account the hierarchical experimental design. The results indicated that the interaction of the cow's udder height, the milker's body height, and the parlor type had a larger effect on ergonomics than each parameter had independently. The interaction was significant in at least 1 of the 3 percentiles in 28 out of 31 ADJ. The postural differences between parlor types, however, were minor. A milking health formula was created to calculate the ideal depth of pit by considering the parlor type, the milker's height, and the mean herd udder height. This formula can be used to develop individual recommendations for future parlor construction.