BASICS: ENDOSCOPIC PLASTIC SURGERY

Endoscopy is a surgical technique that involves the use of an endoscope, a special viewing instrument that allows a surgeon to see images of the body's internal structures through very small incisions.

Endoscopic surgery has been used for decades in a number of different procedures, including gallbladder removal, tubal ligation and knee surgery. However, in the world of plastic surgery, endoscopic instruments have recently been introduced. Plastic surgeons believe the technique holds great promise, but further study is needed to establish its effectiveness, especially over the long-term. As important research continues, endoscopy is being used on a limited basis for both cosmetic and reconstructive procedures.

This brochure will give you a basic understanding of endoscopy in plastic surgery — how it's performed, what risks are involved, and the type of surgical training to look for in a surgeon. Please ask your doctor if there is anything you don't understand about the specific procedure you're planning to have.

The Endoscope

An endoscope consists of two basic parts: A tubular probe fitted with a tiny camera and bright light, which is inserted through a small incision; and a viewing screen, which magnifies the transmitted images of the body's internal structures. During surgery, the surgeon watches the screen while moving the tube of the endoscope through the surgical area.

It's important to understand that the endoscope functions as a viewing device only. To perform the surgery, a separate surgical instrument — such as a scalpel, scissors or forceps — must be inserted through a different point of entry and manipulated within the tissue.

Advantages of Endoscopy

All surgery carries risks and every incision leaves a scar. However, with endoscopic surgery, your scars are likely to be hidden, much smaller, and some of the after effects of surgery may be minimized.

In a typical endoscopic procedure, only a few small incisions, each less than one inch long, are needed to insert the endoscope probe and other instruments. For some procedures, such as breast augmentation, only two incisions may be necessary. For others, such as a forehead lift, three or more short incisions may be needed. The tiny "eye" of the endoscope's camera allows a surgeon to view the surgical site almost clearly as if the skin were opened from a long incision.

Because the incisions are shorter with endoscopy, the risk of sensory loss from nerve damage is decreased. Also, bleeding, bruising and swelling may be significantly reduced. With the endoscopic approach, you may recover more quickly and return to work earlier than if you had undergone open surgery.

Endoscopic surgery may also allow you to avoid an overnight hospital stay. Many endoscopic procedures can be performed on an outpatient basis under local anesthesia with sedation. Be sure to discuss this possibility with your doctor.

In endoscopic surgery, a probe with a tiny camera transmits images inside the body to a video monitor.

Uses in Plastic Surgery

As research continues, it's expected that many new uses for endoscopy will be developed. In the meantime, some plastic surgeons are using the technique on carefully selected patients. Some procedures that may be assisted by endoscopy are:

Cosmetic Surgery

Abdominoplasty (tummy tuck) — Endoscopy is sometimes used as an adjunct for selected patients who have lost abdominal muscle tone. Guided by the endoscope, the muscles that run vertically down the length of the abdomen may be tightened through several short incisions. Endoscopy is generally not used in patients who have a significant amount of loose abdominal skin.

Breast augmentation — Inserted through a small incision in the underarm or the navel, an endoscope can assist the surgeon in positioning breast implants within the chest wall. Endoscopy also may assist in the correction of capsular contracture (scar tissue that sometimes forms around an implant, causing it to feel firm) and in the evaluation of existing implants.

Facelift — Although the traditional facelift operation is still the best choice for most patients — especially those with a significant amount of excess skin — certain selected individuals may benefit from an endoscopically assisted procedure. When an endoscope is used, the customary incision along, or in, the hairline is usually eliminated. Instead, small incisions may be strategically placed in areas where the most correction is needed. If the muscles and skin of the mid-face need to be smoothed and tightened, incisions may be hidden in the lower eyelid and in the upper gumline. To tighten the loose muscles of the neck, incisions may be concealed beneath the chin and behind the ears. The endoscope also may assist in the positioning of cheek and chin implants.

Forehead Lift — Of all the cosmetic procedures that use endoscopy, forehead lift is the one which plastic surgeons more commonly perform. Instead of the usual ear-to-ear incision, three or more "puncture-type" incisions are made just at the hairline. The endoscope helps guide the surgeon, who removes the muscles that produce frown lines, and repositions the eyebrows at a higher level.

Reconstructive Surgery

Flap surgery — Endoscopy can assist in repairing body parts that are damaged from injury or illness. Often, healthy tissue is "borrowed" from one part of the body to help repair another. Using an endoscope, the tissue or flaps can be removed from the donor site with only two or three small incisions.

Placement of Tissue Expanders — Used frequently in reconstructive surgery, tissue expanders are silicone "balloons" that are temporarily implanted to help stretch areas of healthy skin. The newly expanded skin is then used to cover body areas where skin has been lost due to injury (such as a burn) or disease. Using an endoscope, a surgeon can help ensure that a tissue expander is precisely positioned beneath the surface to bring the greatest benefit to the patient.

Sinus Surgery — An endoscope can assist a surgeon in pinpointing and correcting sinus-drainage problems. It can also help locate nasal polyps (growths) or other problems within the sinus cavity, and assist in full rhino-septal surgery.

Carpal Tunnel Release — After the endoscope is inserted through a small incision in the wrist area, the surgeon locates the median nerve, which runs down the center of the wrist. A separate incision may be made in the palm to insert scissors or scalpel to cut the ligament putting pressure on the nerve.

Finding a Well-Trained Surgeon

Because endoscopy is a relatively new technique in plastic surgery, it's extremely important that you select a board-certified plastic surgeon who has adequate training and experience.

Many endoscopic procedures do not require a hospital stay and are performed in a surgeon's office or an out-patient surgery center. If you're planning to have out-patient surgery, be sure that the surgeon you've selected has privileges to perform your particular endoscopic procedure at an accredited hospital. This assures you that your surgeon has been evaluated by the hospital's quality-assurance review committee and is generally considered to have the needed training.

Be sure to find out if the surgeon's hospital privileges cover both the endoscopic and the open version of the procedure you plan to have, since your doctor may have to switch to a traditional open procedure if a complication occurs during surgery.

Keep in mind that many plastic surgeons in practice today received endoscopy training as part of their plastic surgery or general surgery residency training. And all board-certified plastic surgeons are continually being trained in new procedures.

Special Consideration and Risks

It's important to keep in mind that the endoscopic approach has only recently been applied to plastic surgery procedures. There are some known risks, which vary in severity depending on the procedure being performed. These include infection, fluid accumulation beneath the skin (which must be drained), blood vessel damage, nerve damage or loss of feeling, internal perforation injury, and skin injury.

Keep in mind that if a complication occurs at any time during the operation, your surgeon may have to switch to an open procedure, which will result in a more extensive scar and a longer recovery period. However, to date, such complications are rare — estimated to occur in less that 5 percent of all endoscopy procedures.

Deciding if Endoscopic Surgery Is Right for You

Although much is still unknown about endoscopic plastic surgery, you may want to focus on what is known as you make your decision. Considering the following:

For decades, endoscopy has been used successfully in orthopedic, urologic and gynecologic procedures. Improved technology now permits endoscopy to be used by plastic surgeons.

If performed by an experienced, well-trained plastic surgeon, endoscopic procedures may provide the same results as open-method procedures but with less scarring.

In some cases, endoscopic surgery may require less recovery time than is usually required for open procedures.

Patients who tend to be the best candidates for cosmetic endoscopic procedures are those who don't have large amounts of loose hanging skin. Patients with loose facial or abdominal skin may benefit from a combination of classic and endoscopic techniques in face or forehead lift, or abdominoplasty.