Facial Planes Research Articles

Post circumcision Fournier’s gangrene in an infant: A case report

Fournier’s gangrene is a rare life-threatening condition that is characterized by rapid necrotizing spread from the scrotum and perineal area along facial planes to the abdominal wall, the flanks and the upper thighs. We present a case report of post-circumcision Fournier’s gangrene in an infant that was associated with spontaneous rupture of the lower pole of the left scrotum. This report highlights the need for practitioners of circumcision to be skillful in the procedure, use sterile instruments for it and adhere to standard infection prevention and control measures in health facilities.

Which Skeletal Factors Can Affect Lip Canting in Facial Asymmetry?: Statistical Analysis.

Lip canting, which is a noticeable factor in patients with facial asymmetry, can be influenced by the dentofacial skeleton. During orthognathic surgery, postoperative changes in facial soft tissue occur along the newly positioned hard tissue. Therefore, the evaluation of soft tissue before surgery is important. The purpose of this study was to investigate the skeletal factors that can affect lip canting by statistically comparing 2 facial horizontal planes using a three-dimensional reconstruction model. The findings of the present study showed a statistical correlation between lip canting and 3 skeletal factors: menton deviation, maxillary canting, and ramal length differences. Furthermore, a statistical correlation was identified between the Frankfort Horizontal plane and the intercanthal plane compared with the lip canting line. This result suggests that the intercanthal plane could be a standard horizontal plane in three-dimensional reconstruction model analysis.

Modification of surgical and positioning splint for orthognathic surgical treatment of facial asymmetry

Present short communication demonstrates innovative approach for surgical and positioning splint modification, which could improve accuracy of orthognathic surgery during facial asymmetry treatment. Usage of traditionally designed splint leads to the orientation of the midline based just on visual control, which inevitably associated with some level of maxilla deviation. It was proposed to design splint with mutually perpendicular planes in its’ frontal part at the specialized software. Such approach helps to align vertical plane of the splint with the midline vertical facial plane, while horizontal component could be aligned with the horizontal one accordingly. Proposed approach was approbated in five different clinical cases of facial asymmetry treated by orthognathic surgery. In all analyzed cases dental midline aligned perfectly with the planned one, in two cases the midline sagittal plane deviations (from ANS to PNS) resulted to be less than 2°. The horizontal occlusal plane deviations were considered clinically non-significant. Modification of the surgical splint for jaws positioning in orthognathic surgery treatment enables possibilities to check and control position of maxilla regarding reference facial planes intraoperatively, which in turn increases the accuracy of bone fragments placement and assure high precision of orthognathic surgery for asymmetric cases.

Facial fillers: Relevant anatomy, injection techniques, and complications.

The aim of this review article is to discuss the currently available facial fillers, their differences and indications, relevant anatomy, injection techniques, and avoidance and management of complications. Clinical experience and scientific papers. Reversal of facial aging via filler injection has been around since the late 1800s with the initial use of detrimental products. Today, many safe and effective products exist and can be tailored to the individual patient's desired effect. With the evolution of both products and injection techniques, the rate of complications with facial filler use is low. Nonetheless, providers offering facial filler injections should have detailed knowledge of facial anatomy, including facial planes and soft tissue compartments. Multiple injection techniques exist. Different techniques should be used, depending on the anatomic target. Providers should also know how to avoid and manage complications.

Temporal Facelift: A New Method for Temporal and Mid-face Lifting.

Lifting the temporal and mid-face areas creates a very dynamic change in the facial appearance and different planes of dissection were described before. In this article, a new plane of dissection is described which allows the surgeon to perform a very quick and safe dissection in both the temporal and mid-face regions. Patients were operated on using the presented technique and brow lift, cantopexy, and mid-facelift were performed. The outcome of the surgery was analyzed by the authors from standardized photos before and 6 months after the surgery with measurements of the brow and lateral canthus. The plane of dissection is just over the subgaleal fascia which is actually the sub-superficial musculoaponeurotic system layer in the mid-face. This plane of dissection is easy and quick and creates a very mobile mid-face and temporal flap. Forty female patients were operated using the presented technique with a mean follow-up period of 15 months, the longest follow-up was 26 months. No major complication was encountered in these patients. In 5 patients, transient unilateral frontal branch palsy was encountered. In 1 patient, bilateral temporal area depression was observed 8 months after the surgery and treated with a fat injection under local anesthesia. One patient had alopecia in the temporal suture line which can be covered with hair. Temporal facelift is a versatile method with long-lasting results due to its important features; creating a very mobile flap for suspension dissection area, a large surface for adherence, and numerous sutures sharing the tension on the key sutures. Despite its slightly difficult early healing period, the technique should be kept in mind for the rejuvenation of the periorbital area and mid-face. Level of Evidence: Level I.

Are We Correctly Measuring Mandibular Stability After Surgery-First Approach? A Comparative Study Based on Novel 3-Dimensional Measurements.

Using traditional measures to assess mandibular stability after the surgery-first approach (SFA) may produce inaccurate results because unlike the conventional orthodontic-first approach (OFA), the main dental movements occur after surgery in SFA, which produce unavoidable mandibular movements, especially in cases with postsurgical premature dental contact. As these movements are part of the surgical-orthodontic plan, they should not be considered an actual relapse. In this study, to avoid postsurgical dental movement effects, the authors used the relationship between proximal and distal mandibular segments to evaluate stability after SFA. Four easily located points on computerized tomography/cone-beam computerized tomography reconstructed 3-dimensional images were used to calculate 4 measurements between proximal and distal mandibular segments across the osteotomy line in two matched groups of patients (SFA and OFA) at 3 different time points (before, immediately after, and 1 year after the surgery). A high level of skeletal stability was found in the SFA group, with changes 1 year after surgery not exceeding 0.5mm. The SFA was as skeletally stable as OFA, and the mandibular counterclockwise rotation after surgery was related to the planned dental movements and not the instability of the surgery itself. To avoid the illusion of this preplanned relapse, stability should be measured as a relation between proximal and distal mandibular segments, across the osteotomy and fixation line, and not as a relation between maxillary and mandibular landmarks or between the mandible and facial planes as classically described.

Extensive subcutaneous emphysema with pneumothorax in COVID-19

Subcutaneous emphysema is the infiltration of air in the subcutaneous tissues. There are multiple causes of subcutaneous emphysema that can occur, for example, due to surgery, infection, barotrauma, trauma, or spontaneous. In a patient with respiratory failure on mechanical ventilation especially in severe Acute respiratory distress syndrome (ARDS), positive pressure ventilation may lead to subcutaneous emphysema. During positive pressure ventilation, small mucosal injury in the trachea or the bronchi leads air to escape out of the airways. The air then travels along the endovascular bundle into the mediastinum and then follows the facial planes into the neck and subcutaneous tissue of the chest. Positive pressure ventilation may also lead to a pneumothorax due to barotrauma or volutrauma. The subsequent injury to the parietal pleura causes air to leak into the subcutaneous tissue of the chest. This is a 71-year-old female with a history of type 2 diabetes, hypertension, and obesity, who was admitted for acute hypoxic respiratory failure secondary to COVID-19. In the emergency room (ER) her oxygen saturation was 75% on room air, and she was started on supplemental oxygen. Laboratory workup revealed a normal complete blood, count and complete metabolic panel, c-reactive protein (CRP) was elevated at 13.5 mg/dL and COVID-19 polymerase chain reaction (PCR) was positive. Initial chest X-ray was also normal with very mild right lower lobe infiltrate. On hospital day 10, she was intubated for worsening respiratory failure. Seven (7) days post-intubation, chest X-ray (A) revealed significant subcutaneous emphysema (blue arrows). A computed tomography (CT) scan of the chest (B) was obtained which revealed a left pneumothorax (red arrow) with significant subcutaneous emphysema.

Surgical management of Ludwig’s angina under conscious sedation using intravenous combination of dexmedetomidine and ketamine

Background: Ludwig’s angina (LA) is a life-threatening condition, in which there is gangrenous cellulitis of floor of mouth that spreads through facial planes to involve neck region and has the potential to cause airway obstruction. Even though with advent of broad-spectrum antibiotics, it’s incidence has decreased considerably, the anesthetic management of patients, particularly children, undergoing drainage for LA group STILL remains a challenging task. Aims and Objectives: The aim of this study was to test the efficacy and safety of intravenous combination of dexmedetomidine and ketamine (DEXKET) for the drainage of abscess in patients having LA. Materials and Methods: This was a prospective study, in which 40 cases having LA and posted for Abscess drainage were included on the basis of a redefined inclusion and exclusion criteria. Abscess drainage was done under anesthesia using DEXKET as the only intravenous drug. DEXKET was prepared by mixing dexmedetomidine 0.5 mcg/kg along with ketamine 1 mg/kg in a 5 ml syringe and then diluted until 5 ml with distilled water. This was given as bolus dose. Drainage was accomplished under IV (DEXKET) sedation. Results: In this study, there were 28 males and 12 females with a M: F ratio of 1:0.42. The mean age of male and female patients was found to be 38.35±10.58 and 36.41±11.37 years, respectively. Dental caries was the most common cause leading to LA which was seen in 32 (80%) patients. There were no episodes of significant bradycardia, hypotension or desaturation during surgical procedure, as well as in post-operative period. The procedure could be accomplished without any additional doses of DEXKET. Two of the patients (5%) had post-operative nausea and vomiting. Conclusion: Drainage under sedation by intravenous combination of DEXKET is found to be an effective approach for drainage of abscess in cases of LA.

Update on Antimicrobial Therapy in Management of Acute Odontogenic Infection in Oral and Maxillofacial Surgery.

This article focuses on the antimicrobial therapy of head and neck infections from odontogenic origin. Odontogenic infections are among the most common infections of the oral cavity. They are sourced primarily from dental caries and periodontal disease (gingivitis and periodontitis). Many odontogenic infections are self-limiting and may drain spontaneously. However, these infections may drain into the anatomic spaces adjacent to the oral cavity and spread along the contiguous facial planes, leading to more serious infections. Antibiotics are an important aspect of care of the patient with an acute odontogenic infection. Antibiotics are not a substitute for definitive surgical management.

Trendelenburg Gait Improved by Trigger Point and Scar Tissue Lidocaine Injections: A Case Report

This case report describes a 74-year-old Caucasian female patient who presented with bilateral gluteus muscle trigger point pain, decreased gluteus medius strength, a substantial transverse abdominal scar, and a history of knee replacement culminating in a Trendelenburg gait and chronic pain. Treatment of the patients' symptoms with lidocaine solution injections, known as neural therapy, into the bilateral gluteus muscle trigger points and along scar tissue facial planes yielded markedly improved gait and immediate resolution of trigger point pain.

Comparative assessment of various cephalometric facial planes with intercanine width in orthodontic patients.

OBJECTIVE:The study was conducted to evaluate the relationship of various cephalometric skeletal patterns in the vertical and anteroposterior planes with intercanine width in untreated orthodontic patients.METHOD AND MATERIAL:This study included dental cast and cephalometric radiographs of 100 patients (69 females and 31 males) of the age range 13 to 33 years. Skeletal parameters including SNA, SNB, SNMP angles were found from lateral cephalometric radiographs. Intercanine widths including upper intercanine widths (UICW) and lower intercanine widths (LICW) were measured by a digital caliper.RESULTS:The correlation of intercanine width with SNA, SNB, and SNMP angles was analyzed by applying Pearson correlation coefficient. According to statistical analysis, the only insignificant correlation was analyzed between UICW with SNB and LICW with SN-MP.CONCLUSIONS:The overall result showed statistically significant relationship of various cephalometric skeletal patterns in the sagittal and vertical planes with intercanine width.

Comparison of Two Different Doses of Dexamethasone to Control Swelling and Trismus following Mandibular Third Molar Surgery

Introduction: Third molar surgery is one of the most common procedures performed by dental surgeons in clinical practice, where postoperative sequelae like pain, trismus, and swelling are often encountered. Thus, in this study, we compared medications employed to reduce such complications. Objective: To compare the effect of two different doses (4 and 8 mg) of dexamethasone in the control of swelling and trismus after the surgical extraction of mandibular impacted third molars. Methods: An experimental study consisted of twenty-seven (27) healthy adult patients of both genders with bilateral impacted lower third molars, where surgical extraction was indicated, 4 mg and 8 mg of dexamethasone were given orally to the patients 1 hour before the surgical procedure at both the surgeries. The swelling was recorded by measuring the length of 3 facial planes using a measuring tape. Trismus was evaluated by measuring the maximum interincisal distance. Recording of facial swelling and maximum interincisal distance was done preoperatively and on the 1st and 2nd days postoperatively. Results: Based on statistical analysis (Independent T-test), the results showed a difference in the measurements of the degree of swelling and trismus of the treated sample. 8 mg of dexamethasone promoted a greater reduction of symptoms than 4mg of dexamethasone though there was no statistically significant (p-value >0.05) difference between the two doses. Conclusions: 8 milligrams of the dexamethasone had better effectiveness than 4 milligrams of the dexamethasone in reducing the degree of swelling and trismus. Keywords: Dexamethasone; impacted third molars; swelling; trismus.

Hyaluronic acid fillers in facial contouring:The “Less is More” concept

Background: Aesthetic dermatology is a rapidly evolving field of medicine that allows for minimally invasive procedures, little to no recovery time and cost-effective techniques. Hyaluronic Acid (HA) fillers are used for facial contouring, the treatment of facial volume loss & enhancing the natural light reflecting areas of the face. Aims: HA fillers are safe and generally well tolerated yet using more of the product exposes the patient to an added risk of inflammation as well as higher cost. We aim to detail the “less is more” technique that limits the number of injections and maximises natural aesthetic results. The secondary aim of this study is to point out that younger patients consult for a different motive; namely the use of HA fillers for enhancing the natural light reflecting points of the face. Materials & Methods: The “less is more” technique distinguishes between static and dynamic facial planes, allowing for natural expressions, positive patient image, an artistic analysis that encompasses the entire face including untreated facial units. This study was conducted over a period of 30 months on 162 patients divided into two age groups. Results/Conclusions: The “less is more” technique for HA fillers in facial contouring optimizes natural results by selectively diminishing negative facial expressions and allowing for natural looking volume restoration. HA fillers are also effective as a durable tool for enhancing the natural light reflecting areas of the face in patients aged 20-50.

MALIGNANT HEMISPHERIC INFARCTION AFTER SUBTLE TRACHEAL RUPTURE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tracheal rupture after endotracheal intubation is a rare but life-threatening complication with an incidence of approximately 0.005%. Predisposing factor can be a weakness of the membranous trachea secondary to chronic illness or steroid use. Herein we present a case of a young woman who developed a distal tracheal rupture after emergent endotracheal intubation with devastating consequences. CASE PRESENTATION: A 48-year-old female with a medical history of hypertension, epilepsy, and panhypopituitarism secondary to a respected craniopharyngioma was admitted to the intensive care unit with a diagnostic impression of obstructive uropathy with septic shock and multiorgan failure. Supportive management with aggressive fluids resuscitation, antibiotics, dual vasopressor therapy, and endotracheal intubation was given. Hours later, the patient became hemodynamically unstable requiring increased vasopressor therapy with increased demand in ventilation parameters. Physical examination was positive for massive subcutaneous emphysema from her chest tracking through facial and neck planes. A chest computerized tomography (CT) scan was performed and showed a distal tracheal rupture as the most likely cause of the massive pneumothorax that progressed to tension subcutaneous emphysema. Upon acute neurological deterioration, a head CT scan was performed, revealing a left pan-hemispheric malignant ischemic stroke involving the left anterior, middle, and posterior cerebral arteries suggestive of a left internal carotid artery (ICA) complete occlusion. The patient had a National Institutes of Health Stroke Scale score above 20, a left hemisphere infarction, and a GCS 3/11, conferring a poor clinical outcome. As poor prognosis and poor quality of life were expected, the family members opted to withdraw life support. DISCUSSION: Malignant hemispheric infarction has a mortality rate as high as 80 percent with catastrophic neurologic sequelae. Its incidence is less than ten percent of all ischemic infarcts and it's generally caused by embolic occlusion of the ICA. CONCLUSIONS: To our knowledge, there are no malignant hemorrhagic strokes provoked by traumatic intubation resulted from tracheal rupture documented to this day. We presume the etiology of this event to be subcutaneous air that exerted enough pressure between the fascial and cervical planes to result in significant vascular compression. Tracheal rupture is one of the most feared immediate complications of intubation as it could result in increased morbidity and mortality. There is no established consensus for the treatment yet, but early surgical repair has been the mainstay of treatment. However, conservative management has been chosen in cases of small ruptures with similar outcomes. REFERENCE #1: JOSEPH, M. M., & LEWIS, S. (2002). Stroke after penetrating trauma of the oropharynx. Pediatric Emergency Care, 18(3), 179–181.doi:10.1097/00006565-200206000-00007 DISCLOSURES: No relevant relationships by Ian Da Silva Lugo, source=Web Response No relevant relationships by Juan Feliciano-FIgueroa, source=Web Response No relevant relationships by Hector Nunez Medina, source=Web Response No relevant relationships by Héctor Oliveras-Cordero, source=Web Response No relevant relationships by Juan Santiago, source=Web Response

Success rate to complete optimal 20\u2009+\u20092 ISUOG planes for foetal ultrasonographic structural screening during early second trimester pregnancy in Thailand

ObjectiveTo compare the success rates of obtaining optimal 20 + 2 (2 overview + 20 planes) International Society of Ultrasound in Obstetrics and Gynaecology (ISUOG) planes for foetal ultrasound structural screening between pregnant women at gestational age (GA) 18–20 weeks and 20–22 weeks 6 daysMethodsA prospective descriptive study was conducted. Singleton pregnant women at GA 18–22 weeks + 6 days attending antenatal clinic between December 2019 and March 2020 were invited to participate in the study. Women whose foetuses had obvious structural anomalies were excluded. The ultrasound screening using 20 + 2 ISUOG protocol was performed by 21 operators who had completed the online ISUOG basic training programme with an experience of ultrasound scanning of at least 30 cases. The success rates of achieving optimal planes between GA 18–20 weeks and 20–22 weeks 6 days were compared using Chi-square test. Common suboptimal planes in the ultrasound scan were also presented.ResultsOptimal 20 + 2 ISUOG planes were successfully assessed in 97/126 (77%) and 112/126 (88.9%) patients in the group with a GA < 20 weeks and in the group with a GA ≥ 20 weeks, respectively. Overall success rate was 82.9%. The success rate for the GA < 20 weeks group was significantly lower than that for the GA ≥ 20 weeks group. The group with a GA ≥ 20 weeks had a 1.2 times higher success rate than the group with a GA < 20 weeks. The most common suboptimal planes were the facial planes, especially the median facial profile, and foetal thoracic planes.ConclusionsWe prefer to perform foetal structural screening using US with the 20 + 2 ISUOG protocol at a GA 20 to 22 weeks and 6 days with the aim reducing the need for repeat scans.

Determination of Facial References for Esthetic Restorative Treatment.

Although it is generally accepted that a prosthetic restoration must take into account the gingiva, smile, and patient's face, it is often difficult to determine precisely what facial references must be considered. The purpose of this study was to determine the correct vertical and horizontal facial reference planes in esthetic prosthetic treatment. Using photographic analysis of 160 individuals, the different facial reference planes (interpupillary, intermeatic, intercommissural, and incisal edge lines; facial midline; and Camper and Frankfort planes) were compared to the ideal prosthetic reconstruction axis. Additional measurements, including the human eye's ability to perceive parallelism, were recorded. Most participants (64%) exhibited facial asymmetry. Asymmetry was horizontal (difference between widths of the right and left sides; 52.4%), vertical (difference between heights of the right and left sides; 6.9%), or mixed (4.7%). The interpupillary line is the main horizontal reference in 88.4% of situations, with the intercommissural line the second most important. In the profile view, the horizontal plane was on average 6.5 degrees above the Camper plane and 9 degrees below the Frankfort plane. The human eye's ability to perceive parallelism between two lines was found to be limited to differences of approximately 1 degree. During anterior tooth reconstruction, it is necessary to take into account the right horizontal and vertical esthetic references. Knowledge of the biometric facial parameters in natural dentition is necessary to define the right reconstruction axes based on the facial symmetry or asymmetry.

Pleomorphic adenoma of parapharyngeal space: a rare case report

&lt;p&gt;Parapharyngeal space is one of the potential facial planes for neoplasms representing less than 1% of all head and neck tumours, often pose therapeutic and diagnostic problems due to variable nonspecific symptoms and the complex anatomy of the space and tend to delay the diagnosis resulting in poor prognosis. We here with report a 21 years old female patient, who presented with change in voice and swelling in right submandibular area. On examination of oral cavity, a smooth firm bulging mass was seen in the right tonsillar and para-tonsillar region with medialisation of right tonsil. Contrast enhanced computed tomography showed minimally enhancing encapsulated soft tissue density mass in right parapharyngeal space. Patient underwent excision through transcervical approach. Histopathology of the specimen showed pleomorphic adenoma. No evidence of recurrence till date.&lt;/p&gt;

Computer-Aided Design and Manufacturing Cutting and Drilling Guides with Prebent Titanium Plates Improve Surgical Accuracy of Skeletal Class III Malocclusion.

The aim of this study was to evaluate the effects of the use of computer-aided design and manufacturing cutting and drilling guides with prebent titanium plates for the correction of skeletal class III malocclusion. In this prospective, randomized, controlled clinical trial, 46 patients with skeletal class III malocclusion were randomly assigned into two groups. The patients underwent bimaxillary surgery with computer-aided design and manufacturing cutting and drilling guides with prebent titanium plates (experimental group) or computer-aided design and manufacturing splints (control group). Preoperative and postoperative imaging data were collected and then analyzed using Mimics Research 19.0, Geomagic Studio, and IBM SPSS Version 21.0. Deformity evaluation and posttreatment assessment were performed for all patients. The experimental group had fewer postoperative complications. Comparison of the linear and angular differences to facial reference planes revealed more accurate repositioning of the mandible and condyles in the experimental group, although the position of several landmarks still requires small adjustments. Computer-aided design and manufacturing cutting and drilling guides with prebent titanium plates effectively corrected skeletal class III malocclusion, providing positional control of segments with reasonable surgical accuracy. Therapeutic, II.

Iatrogenic Periorbital Subcutaneous Emphysema after Endodontic Treatment – A Case Report.

BACKGROUND: Surgical emphysema is well known and many case reports have been published on this. Many authors have reported this as a complication post dentoalveolar treatment. Diffusion of air into facial planes and periorbital area during endodontic procedures has been rarely reported. The use of three-way air syringe and forceful irrigation of root canal can lead to surgical emphysema of subcutaneous tissue planes in and around the teeth which are involved.&#x0D; CASE REPORT: This case report highlights one such complication seen during endodontic treatment and conservative management of this dental office emergency.&#x0D; CONCLUSION: Endodontic treatment is not frequently associated with the presence of the SCE. However, it is very important to know how to recognize this situation when occurs, to treat the patient appropriately.

Analgesic effect of postoperative laparoscopic-guided transversus abdominis plane (TAP) block, associated with preoperative port-site infiltration, within an enhanced recovery after surgery protocol in one-anastomosis gastric bypass: a randomized clinical trial.

The use of ultrasonography to assist needle placement during transverse abdominal plane (TAP) technique has provided direct visualization of surround anatomical musculature and facial planes. However, the increased girth in patients undergoing bariatric surgery is challenging to visualize via ultrasonography which may lead to poor postoperative analgesia. The aim of the study is to investigate whether the addition of postoperative laparoscopic-guided TAP block as part of a multimodal analgesic regimen within the ERAS protocol compared to no block provides better postoperative analgesia in patients undergoing one-anastomosis gastric bypass surgery. A prospective clinical trial was performed. Patients were randomized into two groups: patients undergoing postoperative laparoscopic-guided TAP (TAP-lap) and patients not receiving TAP-lap (Control). Multimodal analgesia included preoperative port-site infiltration with Bupivacaine 0.25% in both groups and systemic Acetaminophen. Pain quantification as measured by visual analogic scale (VAS) was assessed at 6 and 24h after surgery, and 24-h postoperative opioid consumption. One hundred and forty patients were included, 70 in each group. The mean operation time was 78.5 ± 14.4min in TAP-lap and 75.9 ± 15.6min in Control (NS). The mean postoperative pain, as measured by VAS, 6h after surgery was 23.1 ± 11.3mm in TAP-lap and 41.8 ± 16.2mm in Control (p = 0.001). 24h after surgery was 16.6 ± 11.4mm in TAP-lap and 35.4 ± 12.7mm in Control (p = 0.001). Morphine rescues were necessary in 14.2% in Control and 2.8% in TAP-lap (p = 0.035). Laparoscopic-guided TAP block as part of a multimodal analgesia regimen can reduce postoperative pain and opioid consumption, without increasing operative time.