My name is Andrew Goetze, I'm

a resident physician, this

case and surgery were done under the

direction of Dr. Michael Olson,

one of our sleep in facial plastic

surgery consultants.

This video will demonstrate the

implementation of a hypo glassell

nerve stimulator for obstructive

sleep apnea.

This patient was intolerant to see

Pappe therapy and met

other criteria for hypergrowth nerve

stimulator implantation.

Part of the preoperative workup

includes a drug induced sleep

endoscopy, which is shown here

briefly, which confirms that he

does not have concentra collapse

and that there is, in fact, into

your posterior collapse at the level

of the velum.

Given that he did not have

concentric collapse, he was a

candidate for hyperbolic nerve

stimulation. Here you see the

placement of the electrodes.

The red electrode is placed in the

higher, glossiest muscle, about one

third of the distance posteriorly

and very superficially.

The blue electrode is placed in the

glasses, taking care to protect the

mandibular Duqu papilla

for the incision, the sub mandibular

gland is outlined with the marking

pen.

Here we show the marginal mandibular

nerve course and the

neck incision is placed about one

finger breath below the edge of the

mandible.

The upper chest incision for the

pocket is placed approximately

three fingerprint's below the

clavicle.

And the lateral chest incision

is placed one or two centimeters

below the nipple and then five

centimeters laterally is where you

begin your incision in.

That incision is extended five

centimeters laterally.

Incisions are injected with

local anesthesia.

A lateral shoulder bump

is placed in order to help with the

lateral incision, followed by

prepping and draping at the patient.

Here you see the extent of the

scrubbing of the Betadine, followed

by painting of the

same area, zygomatic arch to midline

all the way down to the umbilicus.

After this has been allowed to dry,

the clear drape

is placed just above

the level of the mandible to

allow for visualization of the

mouth, but to prevent contamination

of the sterile field.

Following this, the band is placed

in a female patient.

It is sometimes helpful.

During the step to media lies the

breast tissue in order to help with

tunneling of the leads later on.

After the patient has been prepped

and draped, incision is made

starting with the.

So mandibular incision.

The incision is taken down to the

ISMA with the 15 blade.

Followed by dissection with a

Joneses scissor and pickup's

palpation of the hyoid bone is

important here is this is your first

landmark you'd like to identify

in order to then follow

the hyoid bone laterally, to

identify the posterior and

enter believe that the gastric

muscle.

Your Kittner is used to better

visualize the gastrique Tinnen.

After the gastric tendon

is identified, it is isolated.

And blue vest loops are used to

further elevate the interior

opposed to your belly so that a

gastric muscle.

At this point, the hyperglycemic

there will be identified just

lateral to the Hollywood and

superiorly and posterior to

the mile high on muscle,

once the nerve

is identified, the microscope

is brought into the field.

You see that gastric muscle, the

Malahide muscle, that

colossal nerve.

And inevitably, there are Iranian

veins that are overlying

and closely associated

with the type of loss on their.

So here we are, isolating

the Iranian Vane's.

In order to get better exposure

of the nerve and control the

bleeding.

And these are suture litigated.

And after the sutures place, this

can be helpful to.

Use that area for traction.

A Kittner is used for traction,

while a McCabe facial nerve

dissector is used to remove

the.

Overlying soft tissue

to expose the nerve.

This is dissected distally

in order to identify the branching

point.

Once branching points come into

view, the bipolar stimulator

is used to identify

the inclusion and exclusion

branches of the hypothalamus on

their.

Obviously, the inclusion branches

will be those that protrude the

tongue and stiffen the tongue and

the branches that reach your

tongue will be excluded from.

The stimulator electro.

The branching point is further

developed here.

The branching

point is once again confirmed.

You see placement of the cuff.

With the McCabe forceps.

There is a rigid portion of the

curve as well as a flexible portion

of the curve.

And after the placement of the cuff

and NGO Cathe is used to

irrigate out any blood

or other fluid that

is collected

between the cuff and the nerve.

Following placement of the

electrodes within

the tick, the microscope out of the

field electrode is in pairs

deep to the possibility

of digestion and

secured to the

gastric tendon with.

Silk sutures, this prevents

tugging on the cuff that

is attached to the nerve.

There are two small grooves

in the stimulator lead

that are designed for tying

this down.

Next, we turn our attention to the

upper chest incision,

the upper chest is the.

Pocket that will receive the

employment pulse generator,

15 blade is used to make the skin

incision and then this

is further dissected down to the

level of the pectoralis muscle.

Ideally, you'd leave the pectoralis

muscle fascia intact

and the implant pulse generator

will sit on top of the

pectorals fashion.

There you can see the Fascher coming

into view.

And then you can use finger and

blunt dissection to.

Create the space for the employing

pulse generator to sit.

Prior to moving on, it's important

to place to securing sutures

that will be used later to secure

the implant pulse generator.

This is done with two

silk suture.

After the chest pocket has been

made, then we turn our attention to

the lateral chest incision.

This will be for the sensing.

The incision is made again with the

15 blade.

And palpation of the

intercostal space is important here.

Incisions taken down.

Through the subcutaneous fat to the

straight into your muscle, which is

the first muscle to be identified.

That muscles and further divided

once again in the intercostal space

to identify the external intercostal

muscles, it's important to be

judicious here as between the

external and internal intercostals

is where this electrode

will sit.

And you're at highest risk here

for a tension pneumothorax, should

the internal intercostals

be violated?

In the full cavity being

exposed to the air.

So here you can see the three

layers, the Sereda center, your

muscle, the external intercostal

muscle and the internal intercostal

muscle.

The introducer is an optional step

that can be bent,

it is a malleable introducer

and that can be placed in between

the external and internal

intercostals in order to create the.

Space and develop the plane where

the sensor will sit

before placement of lead, once

again, it's important to place of

securing sutures.

The sensory lead is placed in

between the internal and external

intercostal muscles.

It's important to get the orientation

of the sensory lead correct.

The bumps on top of the

white securing tab are meant to

be up or

placed superficially,

and that will ensure that the

sensory lead is in the correct

orientation after placement

of the lead.

It is again.

Sutured in place.

A second goal is also use

in order to.

Secure the sensorially.

Next, the sensory wires are tunneled

through the subcutaneous tissues

going from the chest incision down

to the lateral chest first,

it's important to guide this

just beneath the skin.

The wires then attached to the

tunneling device.

And it is.

Drawn back in order to

control the wires.

To the implant pulse generator

pocket.

A similar process is followed

in the sub mandibular area.

It's important to have a stronger

curve here.

This should be placed in the

sub LATISM plane, and

it's really important to avoid the

anterior jugular veins and the

external jugular veins in this

process, as you see here, then

bending the introducer basically

into a U shape.

If we remove the handle.

Secure the wires and then pull the

wire.

Through that tunnel toward

the pulse generator.

The next step is to irrigate all the

wounds, we do this with a

antibiotic solution as

one measure to prevent potential

infection.

The implant pulse generators next

placed.

The leads are labeled and should

be placed appropriately.

Here you see the wrenches used to

bleed the line as the lead is

placed.

Followed by.

Several turns of the

wrench, which one can

hear to secure the

leads in place next to

the securing sutures are.

Place through the implant pulse

generator and.

The important pulse generator is

placed in the pocket.

It's important to put the leads.

Deep to the employer,

pulse generator is.

The battery life on the.

Devices typically 10 to 11

years and will require replacement

at some point and placing the wires

deep to the generator

will protect them for

in the future when the battery

exchange will take place next

month, both the stimulator and the

sensory leads are tested.

You can see protrusion of the

tongue with stimulation.

Finally, the incisions are closed,

there's a second white securing

tab in the sensorially

that is closed,

along with the three incisions

closed with subdermal

sutures and skin glue.

Key points of and nerve

stimulator implantation include

meticulous and very careful,

sterile technique in order to

prevent device infection.

Careful handling of the hyper

colossal nerve and confirmation

multiple times of the correct

branching point and the

inclusion and exclusion branch's

careful placement of the sensorially

between the internal and external

intercostal muscles.

And finally, prior to closure,

testing all the components of the

device to confirm that they are

working properly.