Within the past few years, physician-scientists at a few medical centers around the country, including the Emory School of Medicine, have successfully adapted endoscopic instruments for such procedures as breast reconstruction and augmentation, frown line removal, tummy tucks and face, brow and neck lifts. Researchers have found a way to create a "pocket" under the skin for instrumentation where formally there was none.
"In most endoscopic procedures, instruments that are introduced into the body through small incisions in the skin have some freedom of movement within the body cavity," said John Bostwick, chief of plastic, reconstructive and maxillofacial surgery at The Emory Clinic. "But in plastic surgery, we haven't had that flexibility. We usually are working between layers of skin or delicate layers of muscle and skin."
Imagine drilling a hole in a closet door and slipping poles through it to repair shelves. That's what endoscopic surgery is like for most surgeons. Now imagine slipping those poles through a hole in a bedspread and having to perform surgery between layers of sheets. That is the challenge plastic surgeons have faced.
"The instruments we've developed help us form pockets or tents under the skin that afford us the freedom of movement we need to visualize and transform structures close to the skin's surface," Bostwick said.
Before en-doscopy, surgeons performed breast augmentation "blindly," inserting instruments through incisions under the arms to access muscles and tissue, said Foad Nahai, professor of plastic, reconstructive and maxillofacial surgery. "We went by feel in what we called `closed' or `blind' operations."
Now that images of the surgical target area are transmitted to a television screen via an endoscopic camera, Nahai can more accurately determine just how large a pocket to make behind the nipple to insert the inflatable saline implant.
"I can better evaluate the area and place the implant where I think we'll have the best results," he said.
Nahai said one of the greatest advances the new instrumentation has made to plastic surgery is in the removal of frown or "worry" lines from the forehead. Usually, surgeons make an ear-to-ear incision just behind the hairline above the forehead, then stretch and suture the forehead skin at the incision site. Nahai said that eight-inch incision now can be reduced to three small incisions placed inconspicuously behind the hairline.
The Emory faculty has performed more than 250 endoscopic procedures thus far, about 25 percent of which have been reconstructive and the rest cosmetic. Emory doctors already have taught the techniques to more than 80 of their colleagues around Atlanta and throughout the country. Endoscopic techniques are also being applied to facelifts, where there is not a lot of excess skin, and to defatting and tightening the neck.
Endoscopy is not limited to the breast and face, said Assistant Professor of Plastic and Recon-structive Sur-gery Felmont F. Eaves III. "We have applied endoscopic techniques to all areas of the body. There is great potential for using endoscopic techniques for tummy tucks, breast reconstruction and for other common procedures.
"Theoretically, a properly developed subcutaneous (be-low the skin) endoscopic ex-posure system might allow the use of smaller incisions, the positioning of these incisions in more advantageous locations, and the improved control of dissection in areas of limited visibility," said Eaves in an article published in Perspectives in Plastic Surgery. "Furthermore, a reduction in the extent of required dissection and subsequent tissue trauma might reduce the incidence and severity of complications and postoperative morbidity (illness) compared to that encountered in traditional open techniques."
Thus far, according to Bostwick and Nahai, endoscopic plastic surgery fulfills all these promises. Results have been very satisfactory and complications equal to or less than those expected with open techniques.
-- Lorri Preston