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Plastic Surgery Samples

 

PLASTIC SURGERY POSTOPERATIVE NOTE

HISTORY:  The patient is an 84-year-old gentleman who had excision of a left forehead lesion and left temporal lesion on July 16, 2006.  He returns today with his sutures intact, voicing no complaints. 

PHYSICAL EXAMINATION:  The sutures to the left temporal, left forehead, and donor site to the right chest were removed.  There were no signs of infection, redness, or swelling.  The patient tolerated the procedure quite well.  The full-thickness skin graft has taken well.  There is good blood supply and circulation. 

The pathological report indicated skin to the left forehead basal cell carcinoma, no residual tumor seen; and left temporal skin lesion, Bowen’s Disease, microinvasive squamous cell carcinoma. 

The patient has been instructed to shower and apply bacitracin ointment to excision sites. 

IMPRESSION:  Basal cell carcinoma to the left forehead, no residual tumor; and left temporal lesion, Bowen’s Disease and squamous cell carcinoma.

PLAN:  The patient will return to the clinic in two weeks for a follow-up evaluation. 

BREAST REDUCTION

PREOPERATIVE DIAGNOSIS: 

POSTOPERATIVE DIAGNOSIS: 

OPERATION: Bilateral breast reduction using vertical scar technique.

FINDINGS:  Two pounds were taken from each breast.

INDICATIONS: Macromastia. 

PROCEDURE: The patient was prepped and draped in the usual sterile fashion after general endotracheal anesthesia was obtained.  We began first with the right breast. 

Using a 15-blade scalpel, we excised around the nipple and along a vertical pedicle that traversed in line just above the nipple down to the inframammary crease or just above the inframammary crease.  We took the incisions down with a 15-blade scalpel just through the skin and then used a 10-blade scalpel to de-epithelialize the area.  We next used Bovie cauterization for the entirety of our dissection taking out adequate amounts of fatty tissue from the medial aspects of the breasts as well as the lateral aspects of the breasts, taking care to leave a decent amount of breast tissue along the pedicle for good vascularization and for vascularization of the nipple.

We next dissected in a superior fashion down to the pectoralis fascia and then took this more superiorly along the pectoralis fascia up to the 2nd rib, approximately 2 pounds of tissue was removed.  Next, 3-0 PDS was then used after staples had been applied to reapproximate the skin.  The PDS was placed in buried interrupted fashion taking care to reapproximate the incisions as carefully as possible.

Next, the left breast was done in the exact same manner also taking off approximately two pounds of breast tissue.  Once the PDS was placed in the left side, we next were able to retrieve the nipples through a cruciate incision and bring the nipples out through the appropriate area of the incision.  We next used 3-0 PDS in a running subcuticular fashion to close the incisions leaving a vertical incision as well as a small horizontal component at the bottom of the breast taking care to bunch the area as much as possible for shortening the scars.  The nipples were then inset with 4-0 nylon using half-buried horizontal stitches.  Bacitracin, Xeroform, and dry gauze with an Ace were then applied.  The patient was awakened from general endotracheal anesthesia and sent to PACU in stable, extubated condition. 

 

Breast Reconstruction

PREOPERATIVE DIAGNOSIS: Left breast cancer.  

POSTOPERATIVE DIAGNOSIS: Left breast cancer.

OPERATION: Left mastectomy with sentinel biopsy and reconstruction with tissue expanders.

ANESTHESIA: General endotracheal anesthesia.

INTRAVENOUS FLUIDS: 2400 ml.

ESTIMATED BLOOD LOSS: 25 ml.

COMPLICATIONS: None.

SPECIMEN: Left breast.

INDICATIONS: The patient is a 26-year-old woman with past medical history of left breast mass found to be delta-carcinoma in situ. The patient underwent a left mastectomy with sentinel biopsy and plastic surgery was involved during the surgery for breast reconstruction with tissue expander.

PROCEDURE: The patient was brought into the operating room and received preoperative antibiotics. The patient was placed supine on the operating table and general endotracheal anesthesia was administered by the anesthesiologist. Dr. XXX  performed a left breast skin sparing mastectomy. Once Dr. XXX completed her procedure, the plastic surgical team entered the room.

The pectoralis muscle was raised off the chest wall from the lateral aspect of the muscle. The medial and inferior insertions were not raised to preserve the proper inframammary fold. Hemostasis was maintained throughout the procedure with Bovie electrocautery. Two JP drains were placed in the operating field. One was placed in the axilla and the other underneath the pectoralis muscle. These JP drains were brought out through the midaxillary line. The JPs were then sutured into the skin with silk sutures.

The chest wall was then irrigated copiously with antibiotic irrigation and the tissue expander was allowed to soak in antibiotic impregnated saline. At this point the chest wall was dried and the McGhan 133MV tissue expander, 500 ml volume, was inserted beneath the pectoralis muscle. Once all the air was removed from the expander with a 60 ml syringe, the tissue expander was placed underneath the muscle with the port facing the skin. Three chromic sutures were then used in an interrupted fashion to tack down the right aspect of the pectoralis major muscle to the lateral chest wall with caution as to not puncture the implant.

Once the muscle was secured, the skin flaps were approximated and closed with an interrupted 4-0 chromic subdermal suture followed by a 4-0 Prolene subcuticular closure on the skin. The wound was then cleaned and Mastisol was placed on the edges and Steri-Strips were applied. A gauze dressing was placed on the wound and the patient was awakened from general anesthesia. Instrument counts were correct at the end of the case.

The patient was brought to the recovery room in stable condition. The patient will be admitted to the hospital and be observed over night with IV antibiotics and pain medication.

 

Cleft Lip Repair

PREOPERATIVE DIAGNOSIS: Cleft lip and nose status post repair currently with left alar deformity, irregularity of the left lip and frenulum constriction. 

POSTOPERATIVE DIAGNOS:  Cleft lip and nose status post repair currently with left alar deformity, irregularity of the left lip and frenulum constriction.   

OPERATION: Cleft nose rhinoplasty with ear cartilage graft, frenulectomy, and Z-plasty of the frenulum for lengthening, revision of left lip right lower margin. 

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 10 ml.

INTRAVENOUS FLUIDS: Per anesthesia. 

SPECIMENS: None.

CONDITION:  Stable to PACU. 

INDICATIONS: The patient is a 5-year-old female who has had a cleft lip and alveolus as well as cleft nose in the past.  She had a cleft lip repair done as well as repair of her nose in the past.  She reports here now for final open rhinoplasty of her nose with alar grafting due to irregularity of that site. 

Additionally, she has a significant constriction of her frenulum and scarring at that site from her lip repair, therefore it needs surgical release and Z-plasty.  She also has irregularity of the left lip at the right lower border and requires revision at that site as well. 

The risks and benefits were explained to the patient’s parents and they signed a consent form prior to proceeding to the operating room. 

PROCEDURE: The patient was brought to the operating room and placed in a supine position on the operating table.  General endotracheal anesthesia was obtained.  The patient’s left ear was prepped and draped in the standard surgical fashion and subsequently the incision was made on the columella and subsequently 1% lidocaine with epinephrine solution was injected in the subcutaneous tissues and the nose and subsequently sharp scalpel was utilized to make an incision in the columella in a V fashion.  This was subsequently elevated with sharp Metzenbaum scissors off the medial crura of the lower lateral cartilages.  The skin was subsequently dissected bluntly and sharply with the scissors overlying both cartilages until good separation and visualization of the cartilages was achieved. 

Intercartilaginous incisions were made inside the nostril sills with the sharp scalpel to gain access to the full cartilaginous region.  The left cartilage being irregular, it was dissected free completely and was noted to have significant knuckling or buckling of the distal lateral alar rim.  This area was subsequently trimmed and released of its knuckled and folded over cartilage.  This folded cartilage was noted to be extensive and subsequently resected.  Adequate separation of the medial crura of the lower lateral cartilages was performed to allow for mobilization and freedom to mobilize and replace the alar rims.  Subsequently a Mersilene suture was utilized to shore up or suture approximate the medial crura to provide stability and subsequently interdomal sutures were placed to achieve better aesthetic symmetry and pull the left irregular cartilages medially.  Subsequently, it was noted that there was a lack of support to the soft tissues of the left alar rim and therefore cartilage graft was required. 

Then, 1% lidocaine with epinephrine solution was injected into subcutaneous tissue of the left ear and after adequate elapsed time, sharp scalpel was utilized to take a full-thickness skin graft in the lips followed by cartilaginous donor in rectangular fashion.  Once this was completed, closure of this site was begun after hemostasis was achieved with electrocautery.  Closure as performed with a 4-0 chromic suture in running locking fashion.  Finally, attention was turned to the nasal deformity.  The cartilaginous graft was shaped and subsequently placed into the cavity created for it on the left alar rim.  It was also placed overlapping but underlying the residual alar cartilage on that side.  Once this was completed, a Mersilene suture was utilized to tack it into place in 2 positions and then soft tissue redraping demonstrated good placement with good return of contouring.  Residual dermal membrane was noted and further stenting would be required but the cartilage was providing adequate support at this point. 

Finally with good placement, suture closure of the sill incisions was performed with 4-0 chromic suture in simple interrupted fashion and 5-0 chromic suture in simple interrupted fashion.  Once completed, the columella was noted to be short and requiring significant skin, therefore, the full-thickness skin graft taken from the postauricular region was utilized to repair this defect of the columella base.  The graft was suture approximated with chromic sutures in simple interrupted fashion along the columellar base after it was shaped and subsequently a Xeroform stent was placed over it.  With the left alar rim cartilage in place, slight more membrane was required to be removed and this was performed by taking a piece of the nasal stent.  Subsequently it was sutured into place with a dental roll with Prolene suture.  Once completed, the left lip was noted to have irregularity of the scar repair site of the left cleft lip at the white roll border and this was resected in elliptical fashion along the white roll border and subsequently suture approximated with 6-0 fast-absorbing suture in simple interrupted fashion to recreate the white roll.  After this was completed, under local anesthetic, attention was turned towards the frenulum and 1% lidocaine with epinephrine solution was injected into the subcutaneous tissues of the frenulum and lip and subsequently sharp scalpel was utilized to make Z-plasty incisions.  Once Z-plasties were designed then additional soft tissue bulk was removed from the base of the flaps and subsequently the flaps were tacked into place with 4-0 chromic suture in simple interrupted fashion. 

The patient tolerated the procedure well.  All sponge and needle counts were correct at the end of the case per the operating room staff.  The patient was taken to the PACU at the end of the case. 

Skin Graft

PREOPERATIVE DIAGNOSIS: Right lateral foot wound.

POSTOPERATIVE DIAGNOSIS: Right lateral foot wound.

OPERATION: Debridement of skin and subcutaneous tissue and muscle of right lateral foot wound, pulsatile lavage, and a full-thickness skin graft totaling 50 cm/2.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 50 ml.

INTRAVENOUS FLUIDS: 800 ml.

INDICATIONS: This is a 22-year-old male known well to the plastic surgery service who has had a right ankle fracture that was treated with external fixators and multiple wounds on his right lateral foot who has been using the VAC for the past several months, allowing the right lateral foot wound to granulate and cover over the bone. The wound has been cleaned and has had excellent granulation with a small crevice in the middle of the wound. The patient is here today for debridement, irrigation, a washout, and closing this wound via a skin graft.

PROCEDURE: The patient was brought in the operating room and placed supine. General anesthesia was administered. The patient’s right thigh and right lower extremity were prepped and draped in a standard surgical fashion using a Betadine solution.

The initial portion of the procedure consisted of using a curette to curette out the skin, subcutaneous tissue, and muscle of the wound, eliminating all of the granulation tissue. There was a small hole noted in the inferior portion of the wound which was cleaned out with a curette. There was a crevice in the superior aspect of the wound in the middle of the base, and this was curetted, and a 10 blade was used to create a saucer-type gradual differentiation towards the base of that wound allowing a skin graft to take. A curette was placed in the middle of the wound, showing that there was bone at the base of the wound, but it was covered by some granulation tissue. After this was done, the wound was then irrigated with a 0.25% Betadine solution and then the pulsatile lavage was then used to irrigate out the wound with 3 L of a pulsatile irrigation.

The wound measured a total of 50 cm/2, so a 0.010 inch split-thickness skin graft was taken from the right thigh for a total of this amount of skin. This was then placed dermis side up on the 1.5:1 mesher and then placed through the meshing device. The donor site was covered with Xeroform gauze as well as a bupivacaine-soaked Telfa and overlying gauze and adhesive tape.

The skin graft was then placed dermis side down on the wound and was stapled into position after some moderate amount of trimming to align the proper shape. After this was done, the patient’s right lower extremity was cleansed with some irrigation solution and the decision was made to place a VAC on the skin graft to allow proper adhesion to its bed.

The VAC sponge was then cut to the proper shape and size and then was placed on top of the skin graft which was placed on the right lateral foot. The overlying adhesive dressings were used to make sure that there was no evidence of any air leak. A hole was made and then a VAC connector was then placed on top of this VAC sponge and the VAC was connected to a 125 mm of continuous suction.

After checking the suction, the VAC began to work and the patient was awakened from his general anesthesia. There were no complications during the procedure. The patient was then transferred to the recovery room without further incident.