The term "soft tissue surgery" covers a very large range of procedures from neutering to various surgeries involving the skin as well as the muscles and all of the various internal organs other than the bony skeleton.

From years in general and busy charitable practice, there are a large number soft tissue procedures David is very confident to perform. Below are some of the more technically demanding procedures that David performs.

Total Ear Canal Ablation and Lateral Bulla Osteotomy (TECA + LBO)

This is a salvage procedure. TECA + LBO can be a very effective means for managing severe ear disease affecting the ear canal and/or deeper disease of the middle ear. The whole ear canal is removed and the opening into the bony chamber of the middle ear is opened to allow drainage of debris and infection. The ear flap, or pinna, is left behind in almost all cases. There is normally a big improvement in patient comfort even after such a major operation. Sometimes there is a dramatic improvement in patient temperament which may be as a result of improved comfort.

Patients are often more comfortable following TECA than those undergoing 'less severe' surgeries, presumably because of the more complete removal o abnormal, painful tissues. Some patients will even be more responsive to sounds post-op, even those who have had the procedure performed on both ears. I think this can be attributed to two main factors; that the patient is no longer in chronic pain and that sound will still be transferred to the inner ear through the various bones of the skull. Pre-operatively, the ear canals are often so closed over and the middle ear so full of debris, it must be like trying to listen with ears full of water and fingers plugging your ears.

David has performed more than fifty TECA's, many of them on Shar-Peis with genetically very narrow (stenotic) ear canals. Unfortunately many of these patients have concurrent allergies or allergic type disease affecting the ears making the problems even worse. Inflammation and irreversible thickening of the tissues within the ear canal results in further narrow the ear canal until the canal becomes almost completely closed over and 'end-stage'.

End stage otitis externa secondary to congenital aural stenosis in a Shar-Pei

During surgery, there are various important structures that should be avoided. Dissection can be tricky, especially if the regional anatomy has been distorted by disease. Facial paralysis is a reasonably common complication of surgery. In most cases it will be temporary due to nerve bruising during dissection, but in some cases it may be permanent. Facial paralysis causes the affected side of the face to droop with an inability to blink and to have a floppy lip amongst other issues. There are some very major blood vessels deep in towards the middle ear as well. Although it is very rare, fatal haemorrhage is theoretically possible. If infected material, debris, ear canal tissues or middle ear membranes are not completely removed or if the bony cavity of the middle ear is not sufficiently opened to provide adequate drainage into surrounding tissues, deep seated infection or sinus tracts might develop that might not be completely responsive to drugs alone.  

The most common complications are thankfully minor and include minor wound infection and occasionally a small amount of wound breakdown. This is, perhaps, not surprising since  deep seated ear infection in very narrowed ears is near impossible to completely clear before surgery. 

By removing much of the supportive cartilage for the ear-canal, ear flaps will normally be floppy after surgery and might even flap backwards.

In experienced hands this surgery is very successful.

Ventral Bulla Osteotomy (VBO)

This procedure opens the bony cavity of the middle ear (the bulla) from underneath for the treatment of a variety of middle ear diseases. The ear canal is not removed during surgery, so this procedure is generally not appropriate when the ear canal is not severely diseased. For David, this is most commonly performed to remove small growths, called polyps, from the middle ear of cats.

Vertical Ear Canal Ablation (VECA)

If the tissues around the vertical ear canal are very thickened or if the vertical ear canal is very thickened or diseased but then the horizontal ear canal opens up and is relatively normal, rather than just opening up the vertical ear canal, the whole of the vertical ear canal can be removed.

The horizontal ear canal is re-positioned so that it still exits through the skin, but much lower than the previous opening of the vertical ear canal. By removing the painful and abnormal tissues of the vertical ear canal, these patients are often a lot more comfortable than those undergoing the less invasive lateral wall resection. Following VECA, the ear flap may be poorly supported and more inclined to droop compared to lateral wall resection.

Perineal Hernia Repair

Perineal hernias or 'perineal ruptures' occur when the muscles of the pelvic floor fail on one or both sides of the anus. There are various structures that can pass into the hernial sac(s) including loops of intestine, the bladder, the rectum and the uterus. Most cases are seen in male dogs that have not been castrated. The muscle quality in these patients can be particularly poor and make repair particualrly challenging. Prostatic enlargement in these patients can also lead to excessive straining during defaecation - understandably a problem if there is already pelvic floor muscle weakness.

If operating in an entire male, I always advises castration either some weeks before repair of the rupture or at the same time as the repair of the rupture depending how urgently the hernia needs to be addressed. Castration allows the prostate to shrink in size and reduces straining and therefore pressure on the repair post-operatively. Since it takes several weeks to shrink down, this is best done some weeks before attempting the repair, but in urgent cases, castration might have to be at the same time as conducting the repair.

Where pelvic floor muscles are a poor quality, additional muscle will often need to be recruited from elsewhere to plug the space.

BOAS Surgery

Brachycephalic Obstructive Airway Syndrome (BOAS), as the name suggests, affects brachycephalic (short nosed) breeds and is the obstruction of airflow through the airways. This is typically from having an overlong soft palate that gets sucked into the larynx as the patient breathes, having excessively narrow nostrils and from having excessive scrolls of cartilage in the nasal cavity. A variety of secondary changes can exacerbate the clinical manifestation of the disease.

Most patients respond adequately to widening the nostrils and shorting the soft palate that no further attention is required. This is normally the first step. In more severe cases, where an inadequate response is seen to nostril widening and soft palate shortening, addressing excessive cartilage scrolls in the nasal cavity may be required; this necessitates more specialised equipment and more intensive 24 hour nursing than is typical of first opinion practice and would involve onward referral to a more specialised centre.