PREOPERATIVE DIAGNOSIS:

Aging face.

POSTOPERATIVE DIAGNOSIS:

Aging face.

OPERATION PERFORMED:

1. Rhytidectomy.

2. Upper lid blepharoplasty.

3. Lower lid blepharoplasty with orbicularis suspension.

4. Fat transfer to the central face.

5. Shave excision to the right upper lid.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: Negligible.

FLUIDS: Crystalloid.

COMPLICATIONS: None.

DISPOSITION: To postoperative recovery room in stable condition at the completion of rhytidectomy and blepharoplasty.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position for rhytidectomy and blepharoplasty. SCD hose was in place and functioning prior to the induction of general endotracheal anesthesia. A Foley catheter was placed after the induction of anesthesia. Lacri-Lube was placed in the eyes, and her head and neck was prepped and draped in the usual sterile fashion. Then, 0.5% lidocaine with 1:200,000 epinephrine was injected into the right hemiface. Suction-assisted lipectomy was then performed in the submental region with 2.5 mm cannula

A rhytidectomy incision was performed along the sideburn, the root of the helix, post-tragally around the lobule to the postauricular sulcus with a high mastoid transition to the posterior hairline. A subcutaneous plane of dissection was performed with the skin elevated with help of transillumination. After elevation was performed, SMAS flap was designed along the body and arch of the zygoma. This was elevated from lateral to medial and from superior to inferior. Dissection continued below the angle of the mandible and medially to the zygomaticus major muscle. The flap was elevated in a superolateral direction and fixed to the superficial layer of the deep temporal fascia above the arch of the zygoma using 3-0 Surgilon.

Further inset was performed along the arch and body of the zygoma and along the preauricular area of dissection. The platysma was then advanced to the mastoid where it was affixed with a 3-0 Surgilon. Further inset was performed to the superficial cervical fascia posteriorly and the platysma anteriorly. Meticulous hemostasis was performed. The above was then repeated on the opposite side of the face. A submental incision was then performed with subcutaneous dissection performed. A modest amount of subplatysmal fat was excised with the medial bands of the platysma advanced medially and affixed with 3-0 Surgilon x5. A back-cut was performed at the cricoid cartilage using electrocautery.

The flaps were then elevated, irrigated, and hemostasis assured. The skin flap was then elevated in a superolateral direction with a pilot cut performed and inset performed with a cardinal stitch in the preauricular area with a 3-0 nylon. Cardinal stitch was placed at the apex of the postauricular sulcus using a 3-0 nylon. The redundant skin was excised. Inset was performed with a half-buried 5-0 Prolene along the posterior hairline, with an interrupted 5-0 Prolene along the postauricular sulcus, with a running 6-0 Prolene along the lobule and root of the helix. The tragal flap was defatted with inset performed with a 4-0 Vicryl in the pretragal sulcus with inset performed with a fast-absorbing 5-0 gut. A 7-French drain was placed prior to closure. This was performed bilaterally. The submental area was then closed with a running 5-0 Prolene.

Then, 1% lidocaine with 1:100,000 epinephrine was placed in the proposed pattern skin excision of the upper lids. She had been previously marked, awake in the holding area, for the estimated amount of excision. The amount of excision was again tested with a pinch test. A #15 blade was used to perform the required excision with skin only dissected. The orbicularis remained intact. The orbicularis and septum was perforated nasally with a modest amount of the medial fat pad excised. This was performed bilaterally.

Closure was then performed with a running 5-0 Prolene. This was performed bilaterally. Corneal protectors and Lacri-Lube were placed. Then, 1% lidocaine with 1:100,000 epinephrine was injected into the proposed subciliary incision. A #15 blade was used to make the incision laterally, which was then extended using blepharoplasty scissors.

A subcutaneous dissection was performed to the junction of the pretarsal and preseptal orbicularis with a suborbicular plane of dissection then obtained at this location. The cotton-tip applicator was then used to sweep the fat from the septum to the orbital rim. Electrocautery was used to incise the orbital retaining ligament. A modest amount of fat was excised primarily from the central fat compartment with less fat excised from the medial and lateral fat compartment.

The origin of the orbicularis was incised nasally with previously harvested fat placed in the submuscular plane as a graft. A pretarsal orbicular flap was created, which was then affixed to the lateral orbital rim using a 4-0 Monocryl. The redundant skin was excised with closure performed with a running 6-0 fast-absorbing gut. The above was then repeated on the opposite eye. The corneal protectors were removed, and the eyes were irrigated.

A sebaceous keratosis was shaved from the right upper lid. The periumbilical area was prepped with 40 mL of fat harvested. This was then centrifuged in 3 mL syringes with supernatant discarded. Fat was then injected into the perinasal hollow and the pre-jowl hollow with a Coleman injection needle. An anterior support was placed with 18-gauge needle. The head and neck were then cleansed. Polysporin and Xeroform were placed followed by Kerlix and Flexinet. All sponge and needle counts were correct x2. The patient was then brought to postoperative recovery room in stable condition at the completion of rhytidectomy and blepharoplasty procedure.

PREOPERATIVE DIAGNOSES:

1. Submental lipodystrophy.

2. Abdominal laxity.

POSTOPERATIVE DIAGNOSES:

1. Submental lipodystrophy.

2. Abdominal laxity.

OPERATION PERFORMED:

1. Ultrasonic liposuction, submental.

2. Abdominoplasty with diastasis repair and translocation of umbilicus.

SURGEON: John Doe, MD

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 100 mL.

DESCRIPTION OF OPERATION: The patient was brought to the operating room in the sitting upright position. The submental area was marked for liposuction and the abdomen was marked for abdominoplasty, marking a long, low transverse incision from hip to hip, crossing the pubic hairline and moving onto the opposite side in the identical fashion. The incision was then marked from the edge of that, marking up and around the umbilicus and around to the opposite side.

The patient was then placed supine on the operating room table. General anesthesia was administered and the procedure was begun by tumescence of the submental area with 60 mL of normal saline, incorporating 10 mL of 1% lidocaine with epinephrine. After skin blanch was noted, a 3 mm incision was made in the submental area and the ultrasonic catheter was inserted and approximately 2 minutes of ultrasonic energy used in the submental and neck area, emulsifying fat, and then using a 3 mm cannula, the submental area was liposuctioned until the contour desired was achieved and the thickness of the flap was achieved. A single 6-0 nylon was used to close the incision.

Then, attention was directed to the abdomen which was prepped and draped in a routine fashion. A Foley catheter had been inserted preoperatively. SCD boots had been applied preoperatively and 1 gram of Ancef had been given preoperatively. The procedure was then begun, making a low transverse incision as marked below the top of the pubic hairline, extending from hip to hip and actually beyond the inferior iliac crest on each side. The incision was continued through the subcutaneous tissues using electrocautery down to the fascia.

The flap was then elevated, releasing the scar adhesions up to the level of the umbilicus. An incision was made around the umbilicus, which was quite retracted and scarred in, releasing the umbilicus. Then, the umbilical stalk was dissected down to the fascia. The flap was then divided from the umbilical opening to the free edge and then the flap was elevated above the umbilicus at the fascial plane, separating the subcutaneous tissue from the fascia up to the xiphoid and extending across the costal margins lateral to the xiphoid. Meticulous hemostasis was achieved.

The midline was plicated using #1 Nurolon from xiphoid to pubis and then a second layer was used from pubis to umbilicus using a running locking suture of #1 Nurolon. After this was completed, the wounds were reinspected for hemostasis. Drains were inserted. A drain on the right, lateral to the incision, was brought up and around the upper flap and from the left side across beneath the umbilicus. The bed was then placed into semi-Fowler’s position. The flap was retracted inferiorly.

The incision was then made as marked, extending from hip to hip above the old umbilical opening and the subcutaneous tissue divided with electrocautery and the lateral corners were defatted. Meticulous hemostasis was achieved and the wound was closed in layers, approximating the midline and restoring the midline, which was deviated from previous scarring.

The Scarpa’s fascia was closed with 2-0 Vicryl, the subdermal plane with 3-0 Vicryl and running intracuticular 3-0 Monocryl all the way across. The future position of the umbilicus was marked before wound closure was completed, and this ellipse was then incised and a core of fat was resected. Significant amount of defatting was required to facilitate bringing the umbilicus to the skin level and close the wound, suturing the umbilicus in position with 4-0 Vicryl and a running horizontal mattress of 5-0 nylon. Good contours were achieved.

The patient tolerated the procedure well. A chin strap had been applied around the submental area at the conclusion of the liposuction, and at this time, the wounds of the abdomen were dressed with bacitracin ointment, Adaptic, ABD pads and a gently fitting elastic abdominal binder. The patient was moved to a bed in the semi-Fowler’s position and returned to recovery in good condition after extubation.

Cosmetic/Plastic Surgery Medical Transcription Sample Report #2

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:

1. Submental lipodystrophy.

2. Postpartum atrophy of the breasts with asymmetry, left breast being smaller than the right.

3. Abdominal lipodystrophy.

POSTOPERATIVE DIAGNOSES:

1. Submental lipodystrophy.

2. Postpartum atrophy of the breasts with asymmetry, left breast being smaller than the right.

3. Abdominal lipodystrophy.

OPERATIONS PERFORMED:

1. Submental liposculpturing.

2. Bilateral breast augmentation using subpectoral saline implants.

3. Abdominoplasty.

SURGEON: John Doe, MD

ANESTHESIA: General.

DESCRIPTION OF OPERATION: With the patient positioned in the sitting and the standing position preoperatively, preoperative markings were performed. The patient was then taken to the operating room where the patient was laid in the supine position on the operating room table, and a satisfactory level of general endotracheal anesthesia was obtained. Foley catheter was placed in the bladder. Thromboguards were placed on the lower extremities. and her arms were secured to the arm boards with padded blankets and Ace wraps. The chest and abdomen were prepped with Betadine gel and draped in a sterile manner.

Attention was first turned to the right breast where a submammary incision was made and carried through the subcutaneous tissue to the lateral border of the pectoralis major muscle. A subpectoral pocket was created by means of blunt and cautery dissection, and hemostasis was obtained with cautery. Several sizers were attempted. A 350 mL implant was placed, filled to 380 mL of saline. The contour looked excellent. Attention was then turned to placing sizers on the left side, and it was felt that a postoperative adjustable implant on the left side would be needed. A 325-390 range postoperative adjustable Spectrum saline implant was prepared and placed in the subpectoral pocket. The valve was positioned appropriately in the left anterior axillary line just below the inframammary crease.

After this was completed, attention was turned to irrigating the pockets with bacitracin solution, suctioning all bacitracin from the wound and checking one additional time for hemostasis and closing the wounds with 3-0 Vicryl in the deep tissue, 3-0 Vicryl in the deep dermis, and subcuticular running 4-0 Monocryl. Half-inch Steri-Strips, Xeroform gauze, 4 x 4, and Tegaderms were applied.

Attention was now turned to the abdomen where incision was made on the previously marked incisions of the abdomen and carried down through the subcutaneous tissue to the level of the anterior rectus sheath. Dissection was carried up to the level of the xiphoid. The umbilicus was released from the overlying skin. High-tension abdominoplasty was performed by undermining with sponge stick in the lateral flanks. Hemostasis was obtained with cautery and bacitracin solution was used to irrigate the wound. A Hemaduct drain was placed through the mons pubis and secured with 3-0 Vicryl suture. Attention was turned then to repair of the diastasis in the midline of the abdomen with continuous running double-stranded nylon superiorly from the xiphoid to the umbilicus and horizontal mattress of 0 Ethibond in the lower diastasis.

Once this was completed, attention was turned to bring the patient into general jackknife position. Excessive skin was marked and resected, and hemostasis was obtained. Closure of the abdominal incision was now performed with 0 Vicryl in the deep tissue, 3-0 Vicryl in the deep dermis and subcuticular running 4-0 Monocryl. Attention was then turned to make a transverse elliptical incision in the midline of the abdomen. The umbilicus was delivered and was secured with 3-0 Vicryl and half mattresses of 5-0 nylon.

After this was completed, attention was turned to application of sterile dressings to the abdomen. The patient was placed in a compression garment and a bra was applied. The patient was undraped, and the patient was repositioned. The submental area was injected with 0.5% lidocaine with adrenaline. After hemostasis was obtained as evidenced by blanching of skin, attention was turned to prepping the neck with Betadine gel and draped in a sterile manner. Cross-tunneling liposculpturing was performed using decreasing caliber Klein cannulas until adequate contour had been obtained. The areas expressed excessive fluid.

Closure with 5-0 nylon was performed and attention was then turned to the application of the compression head garment. The patient tolerated the procedure very well. Estimated blood loss was approximately 150-200 mL. The patient received approximately 2000 mL of crystalloids, had good urinary output, and was transferred to the recovery room in jackknife position in good condition. The patient will be admitted for 23-hour observation.

PREOPERATIVE DIAGNOSIS: Multiple complex lacerations of face.

POSTOPERATIVE DIAGNOSIS: Multiple complex lacerations of face.

PROCEDURES PERFORMED:
1.  Irrigation and debridement and complex repair of left cheek laceration.
2.  Irrigation and debridement and complex repair of right cheek laceration.
3.  Irrigation and debridement and complex repair of nasal laceration.
4.  Irrigation and debridement and complex repair of right side nasal laceration.

SURGEON: John Doe, MD

ANESTHESIA: Local 1% lidocaine with epinephrine.

ESTIMATED BLOOD LOSS: Minimal.

DRAINS: None.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Asian male who was assaulted with a bottle and sustained multiple complex facial lacerations. He presents for complex repair of these lacerations. The procedures were explained to the patient including the possible risks and complications, which include but are not limited to bleeding, infection, scarring, possible hypertrophic scar and keloid formation, possible wound breakdown with separation, contour irregularities, asymmetry of one side to the other, sensory changes around the skin area causing numbness, mental nerve injury causing mental nerve deficit, possible bruising, swelling, hematoma or seroma formation. The patient understands, agrees, and wishes to proceed with the repair.

DESCRIPTION OF PROCEDURE: The patient was prepped and draped in a sterile fashion. Lidocaine 1% with epinephrine was used for both anesthetic and hemostatic purposes. Once this was infiltrated to the wound edges and took effect, the wounds were copiously irrigated with saline solution. Hemostasis was then achieved with a cautery.

Some debridement was done with tenotomy scissors. A complex closure was done in multilayer fashion. The left cheek laceration was performed first, this was 4 cmm, followed by the right cheek laceration, which was 3 cm, followed by the nasal lacerations of 2 cm on the bridge and 1 cm on the right side.

They were closed in multilayer fashion utilizing 4-0 Vicryl suture in the subcutaneous tissue plane and the subdermal plane, in interrupted buried fashion. The skin was closed with combinations of running and interrupted 5-0 Prolene sutures. Dressing consisted of Neosporin. The patient tolerated the procedure well.

PREOPERATIVE DIAGNOSIS: Hidradenitis of the mons pubis and bilateral groins.

POSTOPERATIVE DIAGNOSIS: Hidradenitis of the mons pubis and bilateral groins.

PROCEDURES PERFORMED:
1.  Excision of hidradenitis of both groins and mons pubis.
2.  Bilateral gracilis flaps for reconstruction.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General.

DRAINS: Blake drain.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presents for excision of hidradenitis of both groins and mons pubis and bilateral gracilis flaps for reconstruction. The patient was made aware of the nature of the surgery and the risks and benefits associated with it.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room. General endotracheal anesthesia was performed without difficulty. Antithrombotic devices were put on both lower extremities, and the patient’s entire abdomen and both thighs were prepped and draped in a sterile fashion.

An incision was made on the inner thighs. First, the entire mons pubis and upper groin areas were excised down through the entire hidradenitis, which involved the entire mons pubis area. That was totally excised down into the subcutaneous tissue as well as the groin to remove the hidradenitis. Incisions were made then in the posterior aspect of the medial thighs. The gracilis muscle was identified, and an ellipse of skin was taken with the gracilis and a myocutaneous flap with the gracilis muscle was then elevated and swung into the groin on the left side. On the right side, it was used for the upper groin and to recreate the mons pubis. The #19 Blake drains were placed in both thighs.

The incisions in the thighs were closed in layers using 3-0 Vicryl in the deep and a 4-0 Monocryl subcuticular. The flaps were sewn in using 3-0 Vicryl in the deep and 4-0 Monocryl subcuticular. The #19 Blake drain was placed underneath each flap and secured with 2-0 silk. The patient tolerated the procedure well and left the operating room extubated, in good condition, with no apparent immediate complications noted.

PAST MEDICAL HISTORY:  Significant for bipolar disorder. She had no hypertension or diabetes before or after the surgery.

PAST SURGICAL HISTORY:  Significant for Roux-en-Y bypass surgery, laparoscopic hysterectomy, lap cholecystectomy, and right carpal tunnel release, as well as tonsillectomy and adenoidectomies.

MEDICATIONS:  The patient uses Prozac, Lamictal, and calcium.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  She is a nonsmoker, nondrinker, and nondrug user.

FAMILY HISTORY:  Significant for breast cancer in the aunt, grandmother, and great-grandmother and hypertension in her mother.

REVIEW OF SYSTEMS:  Reviewed and significant only for weight loss.

PHYSICAL EXAMINATION:  The examination reveals that the patient has evidence of a large weight loss. She has a two-roll abdomen, and the inferior aspect of the pannus extends below her mons pubis. The skin has a deflated appearance, and the lower roll extends towards her back. There are well-healed laparoscopic scars anteriorly and significant stretch marks. Examination of the abdomen reveals a rectus diastasis but no hernias present on examination. No rashes are noted.

ASSESSMENT:  The patient is status post significant weight loss, still losing weight, not yet appropriate for plastic surgery.

PLAN:  We discussed with the patient that we think it is to be commended how much weight she has been able to lose through the gastric bypass as well as her good habits of diet and exercise. She is not yet appropriate for a tummy tuck, as she has not finished her weight loss. As she has not been at that plateau for six months, she risks the possibility of losing more weight and deflating more, and we recommended that she wait six months after she reaches the plateau because it is possible that she could build muscle and continue to lose more fatty tissue as her body adjusts to its new weight.

We discussed that should she have surgery in the time of weight loss, it is possible that she could have a less than satisfactory result because of excess tissue at that site. We then discussed with the patient very briefly that a tummy tuck involves a long scar extending from hip to hip. For her, because her excess continues around to the back, it may be beneficial to go around the back at some point in the future. We also discussed the possibility of a vertical scar anteriorly with a fleur-de-lis abdominoplasty, but we can discuss that further when she returns after she hits her goal.

We also discussed with the patient the risks and benefits of tummy tuck, including pain, infection, bleeding, damage to neighboring structures, need for further operations, asymmetry of the scar, sensory changes of the abdomen, DVT, PE, and dissatisfaction with the result. The patient will need to have medical clearance prior to going through surgery.

PREOPERATIVE DIAGNOSIS:  Platysmal banding of the neck and facial elastosis.

POSTOPERATIVE DIAGNOSIS:  Platysmal banding of the neck and facial elastosis.

OPERATION PERFORMED:  Platysmaplasty with liposculpturing of the neck.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  With the patient positioned in supine position on the operating room table, satisfactory level of general endotracheal anesthesia was obtained. Attention was turned to injecting the neck with 0.5% lidocaine with adrenaline. As hemostasis was being obtained, attention was turned to scrubbing the neck and supraclavicular area with Betadine gel and draped in sterile manner.

Attention was then turned to submental incision, which was carried down to the level of the subcutaneous fat. The platysmal muscle was identified. Facelift incisions were used to dissect the skin off the platysma muscle to the lateral markings on each side. After this was completed, the medial aspects of the platysmal bands, which have been previously marked, were identified. At the cricoid cartilage, the platysmal bands were back cut for approximately 3 cm, and hemostasis was obtained. The wound was irrigated with bacitracin solution.

Attention was turned to creating platysmaplasty by suturing the platysma to the midline with interrupted 3-0 Vicryl. Once this was completed in double layer fashion, attention was turned to irrigating the wound again with bacitracin solution. After this was completed, the liposculpturing cannula was used to liposculpture the underside of the skin to stimulate the skin for contraction purposes, and after this was completed, the skin was redraped and a small amount of skin in submental region was resected. Hemostasis was obtained.

The incisions of the ear were closed with 5-0 nylon. The incision in the submental area was closed with 5-0 Vicryl and 5-0 nylon. Half-inch Steri-Strips were applied. All areas were cleansed. The patient was placed in compression garment and tolerated the procedure extremely well and returned to the recovery room in excellent condition. Her husband was given homecare instructions. The patient was discharged in good condition and will follow up in the office in a week’s time and will call for any problems.

PREOPERATIVE DIAGNOSES:
1.  Nasal deformity.
2.  Chin recession.

POSTOPERATIVE DIAGNOSES:
1.  Nasal deformity.
2.  Chin recession.

OPERATION PERFORMED:
1.  Rhinoplasty.
2.  Chin augmentation.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was admitted to the preoperative holding area. While in the supine and semi-sitting positions, the stair-step columellar incision as well as pertinent nasal anatomy, including dorsal hump, widened nasal base, widened alar base, and excessive alar cartilages were marked with a surgical pen. The patient received 1 gram of Ancef preoperatively. Bilateral SCDs were placed. The patient was then brought back to the operating suite and placed supine on the operating table. Both SCDs were made functional, at which time general anesthesia was then induced. An endotracheal tube was secured with a 2-0 silk suture. This will be removed at the completion of the procedure. A throat pack was also placed as was a Foley catheter. Tetracaine eye drops, Lacri-Lube ointment, and bilateral corneal protectors were placed. A total of 12 mL of 1% lidocaine with epinephrine was infiltrated in the soft tissue of the nasal area, including bilateral infraorbital nerve blocks. The patient’s face was prepped with Betadine and surgically draped. Oxymetazoline packs were then placed into the internal nasal vestibule bilaterally.

After adequate time had transpired, the previously marked stair-step transcolumellar incision was opened with a #11 blade scalpel. The mid portion of the lower alar cartilages at the columella was then identified and a supraperichondrial plane dissected over the chip area, including the width of cephalically rotated lower lateral cartilages. Next, the dorsal caudal septum was exposed and the dissection proceeded up to the nasal bones, which were found to have a convex shape as well. The subperiosteal elevation of the nasal bone area centrally was then performed. After initial antibiotic irrigation and hemostasis, the osseous portion of the dorsal hump was rasped with Snowden-Pencer #5 and #6 rasps. Next, the dorsal septum was trimmed with Micrins super sharp septal scissors commensurate with the height of the nasal bones. After checking the profile under direct vision as well as with the skin redraped, the lower lateral cartilages were then marked and alar strip resection, leaving 5 mm of alar cartilage inferiorly along the entire length of the cartilage, was then performed. With the cartilages in repose, the domes matched symmetrically.

Next, a partial transfixion incision was made along the caudal septum, at which time conservative resection of the caudal septum was made. Next, a partial bilateral inferior turbinectomy was performed with scissors followed by cauterization. No excessive bleeding was seen during the entire procedure. The nasal cavity was then irrigated with Betadine followed by antibiotic solution. Next, the intranasal incisions were closed with interrupted 4-0 chromic suture. A single 6-0 buried clear Vicryl suture was placed at the mid portion of the dermis of the transcolumellar incision. The remaining columellar incision was closed with interrupted 6-0 nylon sutures. Next, 3 mm Weir excisions were made at the alar base. After these triangulated skin wedges were removed, hemostasis was achieved followed by antibiotic irrigation and single dermal suture closure at each incision. Final skin closure of these areas was performed with running 6-0 nylon sutures. It should be noted that bilateral low-to-high osteotomies through a combination of intranasal as well as percutaneous approach were performed bilaterally prior to the Weir excisions. Next, a soft splint followed by an aluminum Denver splint were placed in addition to bilateral Merocel nasal packings with an internal airway that was soaked with bacitracin ointment. Both packs were secured with an external 2-0 silk suture to prevent any postoperative aspiration.

Finally, attention was directed to performing the chin augmentation. With the chin implants soaked in antibiotic solution, bilateral mental nerve block as well as infiltration of the precise pocket, measured prior to surgery, was performed using 1% lidocaine with epinephrine. After adequate time had transpired, a 2.5 cm intraoral incision was made 6 mm inferior to the intraoral mandibular vestibule. The dissection proceeded subperiosteally, centrally, avoiding exposure or injury to the bilateral mental nerves. The inferior pocket along the jaw line was then developed with Freer elevators. After initial Betadine followed by antibiotic irrigation, the extended median anatomic Implantech chin implant was placed into the pocket in a precise location.

Next, additional antibiotic irrigation was performed and incision closed with three interrupted 4-0 Vicryl sutures. The patient tolerated the procedure well. Estimated blood loss was less than 20 mL. All sponge and needle counts were correct. There were no complications. Foley catheter was removed prior to extubation as was a lower Bair Hugger used to prevent intraoperative hypothermia as was the throat pack. In addition, bilateral corneal protectors were removed, and irrigation with balanced salt solution was performed. The patient was extubated in the operating room and transferred to the recovery room in stable condition.

PREOPERATIVE DIAGNOSES:
1.  Hypovolemic breasts.
2.  Redundant abdomen.
3.  Lipodystrophy, hips and knees.

POSTOPERATIVE DIAGNOSES:
1.  Hypovolemic breasts.
2.  Redundant abdomen.
3.  Lipodystrophy, hips and knees.

OPERATIONS PERFORMED:
1.  Bilateral augmentation mammoplasty, 450 mL saline prosthesis, submuscular.
2.  A mini abdominoplasty.
3.  Suction lipectomy, hips and medial knees.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was marked for three separate procedures. She was given a general anesthetic. We first began by infiltrating the iliac crest area and the medial knees with tumescent solution, and suction lipectomy was performed in each of the four areas through two ports using a 4 mm cannula. This resulted in pleasing contours. All wounds were closed with buried interrupted 4-0 Vicryl sutures. Steri-Strips and dressings were applied.

We then began by making bilateral inframammary crease incisions 4 cm in length. Dissection was carried down through subcutaneous tissue to the chest wall. Subpectoral pockets were created of adequate size and of equal size. They were checked for adequate hemostasis. Because of the redundancy of her skin envelope, the breast tissue above the pectoralis inferomedially was dissected off the pectoralis, and the pectoralis was then released toward the sternum. Adequate hemostasis was checked again. Multiple sizes were placed, and 450 mL seemed perfect.

The wounds were copiously irrigated one more time and checked for hemostasis. Four 4-0 Vicryls were placed in the subcutaneous tissue. The implants were placed and inflated to 450 mL . The Vicryls were tied down and another layer of interrupted 4-0 Vicryls were placed and a running 5-0 nylon.

Then, attention was turned to her lower abdomen where a suprapubic, semicircular incision was then made and dissection carried down through subcutaneous tissue and fascia to the abdominal wall. This skin fat flap was then elevated to the umbilicus. Adequate hemostasis was checked x2. The midline fascia was imbricated with buried interrupted figure-of-eight #2 Tevdek sutures. Adequate hemostasis was checked again. A single Jackson-Pratt drain was placed through a suprapubic stab wound. The redundant tissue was then excised, excising about 10 cm of skin in the midline.

Adequate hemostasis was obtained. The wound was closed with two layers of buried interrupted 3-0 Vicryl and then running subcuticular 4-0 Monocryl. Steri-Strips were applied as well as compressive dressing. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.

PREOPERATIVE DIAGNOSIS:  Squamous cell cancer, right scalp.

POSTOPERATIVE DIAGNOSIS:  Squamous cell cancer, right scalp.

PROCEDURES PERFORMED:
1.  Excision of squamous cell cancer, right scalp.
2.  Full-thickness skin graft to right scalp.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  Twenty-six mL of 1% lidocaine with epinephrine and 0.25% Marcaine plain, 1:1 mix.

SPECIMENS:  One lesion from right scalp, 5 x 5 cm.

COMPLICATIONS:  None immediate.

BLOOD LOSS:  Minimal.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic male who presents with a biopsy-proven squamous cell cancer of his right scalp. The patient is a transplant patient and has many comorbidities, so a large resection will be performed. The patient was consented for the procedure and understands the risks and benefits of the procedure, which include potential graft failure, scarring, and recurrence of cancer.

DESCRIPTION OF OPERATION:  After explaining potential risks and benefits of the procedure to the patient, written consent was obtained, and the patient was taken to the operating room by gurney and transferred to the operating table in the supine position. Local anesthetic, listed above, was infused in the scalp and in the right supraclavicular area.

The dimensions to be excised were marked, 1.5 cm margins were made around the perimeter of the lesion, and a similar full-thickness skin graft was then taken from the supraclavicular area. Donor site was then closed primarily with 3-0 Vicryl sutures deep and a running 4-0 Monocryl superficially. Hemostasis was achieved with electrocautery prior to closure.

The full-thickness skin graft was then defatted and placed into the defect. The excised lesion was sent to pathology and marked in superior and anterior borders. Once the skin graft was placed, it was sewn into place with 4-0 chromic sutures deep and 5-0 nylon tie-over bolster was fashioned. The patient tolerated the procedure well without any immediate complications.

PREOPERATIVE DIAGNOSIS:  Acquired defect of nose, status post Mohs excision of basal cell cancer.

POSTOPERATIVE DIAGNOSIS:  Acquired defect of nose, status post Mohs excision of basal cell cancer.

OPERATION PERFORMED:  Bilobed myocutaneous local flap reconstruction.

ANESTHESIA:  MAC with local 1% lidocaine with epinephrine and 0.5% Marcaine 1:1, 10 mL total.

SURGEON:  John Doe, MD

SPECIMENS:  Skin from nose around Mohs defect.

ESTIMATED BLOOD LOSS:  Minimal.

DISPOSITION:  Stable to same day surgery.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic male who presents with a defect approximately 1.4 cm in greatest diameter on the dorsolateral tip of his nose. The defect is not full thickness. There is intact cartilage underneath of the wound. Assessment was done preoperatively, and the determination of a local bilobed flap would be appropriate. The patient was consented for the procedure and understands the risks and benefits of the procedure, which includes scarring, bleeding, and infection.

DESCRIPTION OF OPERATION:  After explaining potential risks and benefits of the procedure to the patient, written consent was obtained. The patient was taken to the operating room by gurney and transferred to the operating room table in a supine position. Monitored anesthesia care was initiated and 1 g of Ancef was given preoperatively. Once the patient was under MAC, 10 mL of the above listed local anesthetic were infused over the dorsum and the lateral aspects of the nose to hydrodissect a plane off the perichondrium and bony vault. The face was then prepped with Betadine paint and draped in a standard sterile fashion. A time-out was performed to indicate the patient, procedure, and site to be operated on.

First, we began by marking out the proposed flap. This was laterally based on the right side and bilobed in nature, containing both the muscle and skin and subcutaneous layers. After this was done, it was incised with a 15 blade and then the entire dorsal and lateral aspects of the nose were degloved off of the periosteum and perichondrium.

With this mobile skin, we then rotated the bilobed flap into position, and the donor site was closed primarily with 4-0 PDS sutures deep and 6-0 nylon running suture superficially. The flap was inset into the defect, which had been previously trimmed and a small Burow’s triangle was removed and sent for pathology. It was secured into place likewise with 4-0 PDS suture deep and 6-0 nylon interrupted suture superficially.

Prior to closure, hemostasis was achieved with electrocautery and pressure. The patient tolerated the procedure well without any immediate complications. A layer of bacitracin and sterile gauze was placed over the incision. The patient tolerated the procedure well.