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--- resident:brooke_french [2019/11/07 18:36] – [Cleft Physician Preference] melissa
+++ resident:brooke_french [2022/05/24 18:01] (current) – [Breast Reduction] ally
@@ Line 1: / Line 1: @@
-====Dr. French Introduction====
+=====Dr. French Introduction=====
   * 1995-1999: Undergraduate - University of Illinois, BS Biology\\
@@ Line 11: / Line 11: @@
 =====Operations=====
-====Female to Male Chest====
+**General Tips:**\\
-Patient was marked in standing position in pre op and then taken to OR for GETA.  After SCD boots placed and antibiotics given, 60 cc of tumescence fluid injected into proposed areas of liposuction and excision.  Prepped and draped in sterile fashion.  3.7 mm cannula used with SAL to tail of breast bilaterally for total of 50 cc lipoaspirate.  Thereafter, a 10 blade scalpel used to excise a bilenticular area from the lateral aspects of the breasts and chest wall to improve contour.  Bovie used to complete the excision and then undermining was undertaken superiorly and inferiorly.  Care was taken to stay superficial to underlying nerves.  Irrigation undertaken and hemostasis achieved.  Wounds closed in layers with 3-0 vicryl for deep dermal sutures and then 4-0 monocryl for running subcuticular suture.  Dermabond and op site dressings applied.  An abdominal binder was placed.
+Dr. French will ALWAYS ask you questions in OR so be prepared!\\
+====ORIF Mandible with MMF====
+<WRAP group>
+<WRAP half column>
+Indication: R parasymphyseal mandibular fracture, bilateral mandibular condyle fractures, alveolus lacerations/avulsions, multiple teeth loss 2/2 MVC trauma
+Risks and benefits have been discussed including but not limited to blood loss, infection, poor wound healing, notable scar, paralysis and facial asymmetry and potential need for future revisions/surgeries. Questions have been answered and all wish to proceed.
+Local infiltration into lower mandibular sulcus and across fracture.  Teeth brushed with peridex and face prepped and draped in sterile fashion.  Throat pack placed.  Right lower parasymphyseal fracture was open and very mobile.  Upper rapid MMF arch placed with 6 mm screws, tipping screw holes away from roots.  Upper lacerations closed with simple and horizontal mattress sutures of 3-0 vicryl.
+Opened the lower incision with cut on the bovie and left cuff of mentalis to sew to.  Visualized right mental nerve as intact and exposed and reduced fracture.  Placed lower border plate and then placed MMF of lower jaw.  We then wired her shut and were dissatisfied with occlusion so removed plate and rewired her into what appeared to be normal occlusion with wear facets.  Then replaced lower border plate with 10 and 12 mm screws and then placed a miniplate superiorly with 4 mm screws.  Released MMF and looked good so replaced after closed reduction of bilateral condylar fractures and removal of throat pack.  Sewn closed with 3-0 vicryl for muscle and 4-0 vicryl for mucosa.  26 gauge wires were used.  NG used to suction stomach.
+The patient tolerated the procedure well and was transferred to the care of ENT, ortho and trauma. All sponge and needle counts were correct at the end of the case.
+</WRAP>
+<WRAP half column>
+Prep: Peridex, brush teeth\\
+Sutures: 3-0 vicryl for muscle, 4-0 vicryl for mucosa\\
+Pimp questions: \\
+  * Basic anatomy, location of mental nerve
+  * Malocclusion types
+  * How many teeth do children have vs. adults? 20 vs. 32
+  * Which tooth root is the longest? Mandibular canine
+</WRAP>
+</WRAP>
+==== Brachioplasty ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Bilateral Brachioplasty\\
+\\
+Patient was marked in the preanesthesia area and brought to the operative theater.  After adequate GETA was undertaken, the patient was prepped and draped in sterile fashion.  Appropriate DVT prevention interventions undertaken and perioperative antibiotics were provided.\\
+ \\
+First we injected 1000 cc of tumescence to the arms that were pre operatively marked.  After adequate time period had passed we performed liposuction to arms.  We excised the tissue above the fascia and excised skin in the axilla and then a small ellipse on the chest wall.\\
+ \\
+Irrigated, hemostased and then closed in layers. \\
+Abdomen addressed with inferior incision and elevated off fascia.  Rectus repaired with figure of 8 neurolons and then flexed at waist to determine amount of skin resection.  This was removed and dog ears were excised.  Central vertical portion was removed and umbilicus was inset.  All closed in layers over 2 15 blake drains.  Thrombin and local sprayed and injected respectively.  Dressings applied. \\
+ \\
+Needle, sponge and instrument counts were correct at the conclusion of the case.  I was present and scrubbed throughout, performing or directing all key aspects of the case.  There were no complications apparent.  Patient was extubated and transferred to PACU in stable condition.
+</WRAP>
+<WRAP half column>
+Photos\\
+Drain: 15 blake drain in each side. If necessary.\\
+Sutures: 2-0 vicryl if there is a SFS layer possible to close, 3-0 monocryl deep dermals, 4-0 monocryl running subcuticular.\\
+Dressing: Large steri-strips (no benzoin or mastasol). Kerlix/ACE from fingers to axilla.\\
+Anatomy: Know the different techniques for brachioplasty. The pre-operative markings are key. The most commonly injured nerve is the medial ante-brachial cutaneous.\\
+Post-operative care: No lifting greater than 5 lbs.\\
+Learning points/Pimp Questions: Tumesce and lipsuction first. You will dissect at the catacombs. Do not do liposuction in the axilla... take that skin off full thickness.\\ A tip for suturing is to slide a malleable retractor into the wound to push the fat out of the way so you can suture just the dermis and not be struggling with the fat herniating out of the wound. Basically she tumesces and liposucts. Then she divides the sections likely into 3. The superior line is the set line (just above the bicipital groove), so you go section by section and adjust the inferior line. Pro move- grab the epidermis inside the wound to test it instead of ripping and stretching the skin where you will be suturing to.\\
+</WRAP>
+</WRAP>
+====Female to Male Top Surgery====
+<WRAP Group>
+<WRAP half column>
+Pre/Post Procedure Diagnosis:  Gender dysphoria\\
+Procedure: Bilateral mastectomy with free nipple/areolar grafts and liposuction flanks and IMF\\
+Patient was marked in the preanesthesia area and brought to the operative theater.  After adequate GETA was undertaken, the patient was prepped and draped in sterile fashion.  Appropriate DVT prevention interventions undertaken and perioperative antibiotics were provided.\\
+We infiltrated tumescence fluid into bilateral breasts, flanks and along the IMF.  While that was setting up, we harvested the areolar grafts as full thickness grafts using the 25 mm marker.  These were defatted and set into saline guaze for later use.  We had marked the patient preoperatively for excision mastectomy and these marks were confirmed.  We used VASER liposuction and then suction assisted liposuction to the lateral breasts on the flanks and across the IMF to obliterate this distinct mark as feminizing.  We then made the inferior incisions and used bovie to excise the breast tissue bilaterally, leaving a flap consistent with superior chest and lower abdominal thickness to match contour.  This resulted in leaving some breast tissue on the flaps as well.  These were then excised from the pre pec fascia and sent as specimen.  Adjustments were made with face lift scissors and bovie to desired symmetric contour.  Copious irrigation undertaken and hemostasis achieved.  We placed drains bilaterally and brought out through stab incisions laterally.  These were sutured into place.  We then placed progressive tension sutures to obliterate dead space with 2-0 vicryl in 3-4 locations on each side and sprayed thrombin into the cavities.  We stapled closed and then closed in layers with 2-0 for SFS and then 3-0 monocryl for deep dermals and 4-0 monocryl for running subcuticular sutures.  We then sat the patient up and measured and marked the NAC at lower border of lateral pecs.  This area was marked and deepithelialized for reception of the grafts.  These were inset with chromic and silk bolsters were sewn atop xeroform.  Dermabond and op site dressings applied.  An abdominal binder was placed.
+</WRAP>
+<WRAP half column>
+Drain: No\\
+Sutures: 2-0 vicryl for SFS and progressive tension sutures, 3-0 vicryl for deep dermal sutures and then 4-0 monocryl for running subcuticular suture\\
+Dressing: Dermabond and op site dressings applied. Abdominal binder for compression.\\
+Starts with tumescence.\\
+Dr. French uses liposuction to obliterate IMF and to thin out the tail of Spence.\\
+Hemostasis is critical and she will progressive tension sutures, thrombin, and compression.\\
+</WRAP>
+</WRAP>
+====Scalp Tissue Expander====
+<WRAP Group>
+<WRAP half column>
+Patient was marked in the preanesthesia area and brought to the operative theater.  After adequate GETA was undertaken, the patient was prepped and draped in sterile fashion.  Appropriate DVT prevention interventions undertaken and perioperative antibiotics were provided.
+She was positioned prone and appropriately padded.  We injected local into her scar and knife and bovie were used to incise the scar.  We hoped to excise some of the scar but were unable at the end due to tension.  I bluntly dissected above the periosteum with bovie, malleable, and uterine dilators to accommodate the 8 x 18 cm implant.  We then irrigated copiously with antibiotics and saline and then assured hemostasis.  We soaked the implant in the same solution and then sucked out the air through the internal port.  We placed 10 cc of methylene blue and injectable saline in the implant and then placed the implant without folds.  We then accessed it through the skin and injected another 10 cc for a total of 20 cc.  We then closed the skin in layers with 3-0 vicryl for deep sutures and 4-0 prolene in the skin.  Scalp was cleansed and dried and bacitracin was applied.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 3-0 vicryl for deep sutures and 4-0 prolene
+Dressing:No\\
+</WRAP>
+</WRAP>
+====Facial Feminization====
+<WRAP Group>
+<WRAP half column>
+Pre/Post Procedure Diagnosis:  Gender dysphoria
+Procedure:
+.  Forehead reduction/set back and contouring
+.  Bilateral brow lift
+.  Division corrugators
+.  Anterior hairline advancement flap 20 x 4 cm
+.  Bilateral mandibular angle and ramus reduction/contouring
+.  8 mm genioplasty setback
+Surgeon:  Brooke French, MD
+Assistant:  Jonathan Freedman, MD resident
+Anesthesia:  GETA
+EBL:  100 cc
+IVF:   See op note
+Specimen:  None
+DOS:  10/31/19
+Complications:  None
+Condition:  Patient is extubated and transferred to PACU in stable condition
+I have discussed the risks, benefits, alternatives and the procedure itself, including, but not limited to, pain, infection, bleeding, injury to surrounding structures, need for reoperation, recurrence, scarring, persistence of symptoms and asymmetry.  The patient understands the typical perioperative course with the need/potential for dissatisfaction with results.  All questions have been answered to the best of my ability.
+Patient was marked in the preanesthesia area and brought to the operative theater.  After adequate GETA was undertaken, the patient was prepped and draped in sterile fashion.  Appropriate DVT prevention interventions undertaken and perioperative antibiotics were provided.
+VSP had been performed to increase operative safety, efficiency and speed.  First performed a bicoronal incision, diving into the hairline past the temporal recession bilaterally.  Scalp flaps were reflected above the periosteum, taking care to stay deep below the temporal branch of the facial nerve.  7 JP drain placed posteriorly.  Anteriorly based pericranial flap elevated and ultimately lain atop the forehead reconstruction and sutured to native scalp periosteum posteriorly for vascularized support of frontal bone graft.  Cutting guides used to mark out the proposed cuts and then sonopet used to remove and horizontally split the anterior table inside the pneumatized sinus.  This was placed in modling and plating guide and secured with plates and screws in the inner table.  4 plates and screws used along the outer table to secure into new recessed position.  Burr used to then take down the lower forehead to appropriate level by drill guides that were marked and stained with pen.  We secured the brow into position and then made adjustments with the burr.  Corrugators accessed through galea and divided, protecting branches of supratrochlear nerves.  We then advanced the brow superiorly to elevate the brow, while advancing the hairline inferiorly, particularly at the temporal recession regions.  Part of non-hair-bearing forehead was excised in this region bilaterally and the flaps were brought forward and stapled.  We placed the drain, irrigated and assured hemostasis.  Closed in layers.  Local injected into chin and mandibular region bilaterally.  Teeth had been brushed with peridex and throat pack placed.  First the mandibular reduction undertaken with sonopet to 3 -4 mm bilaterally.  Washout and closure undertaken.  Then genioplasty performed with gingivobuccal sulcus incision and protection of bilateral mental nerves.  Calipers used for measurement and sonopet and oscillating saw used to taper the cut.  Freed and set back 8 mm with stair step Stryker plate and 8 mm screws.  Interferences or step offs burred with sonopet.  Closed in layers and OG used after throat pack out.  Headwrap and jaw braw applied.
+Needle, sponge and instrument counts were correct at the conclusion of the case.  I was present and scrubbed throughout, performing or directing all key aspects of the case.  There were no complications apparent.  Patient was extubated and transferred to PACU in stable condition.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 7 JP\\
+Sutures: No\\
+Dressing:No\\
+</WRAP>
+</WRAP>
+====BBA/abdominoplasty====
+<WRAP Group>
+<WRAP half column>
+Pre/Post Procedure Diagnosis:  Breast ptosis and excess skin abdomen with severe rectus diastasis
+Procedure:
+.  Bilateral breast augmentation silicone 325 cc submuscular dual plane
+.  Abdominoplasty with rectus plication
+I have discussed the risks, benefits, alternatives and the procedure itself, including, but not limited to, pain, infection, bleeding, injury to surrounding structures, need for reoperation, recurrence, scarring, persistence of symptoms and asymmetry.  The patient understands the typical perioperative course with the need/potential for capsular contracture, mastopexy or need to repair hernia.  All questions have been answered to the best of my ability.
+Patient was marked in the preanesthesia area and brought to the operative theater.  After adequate GETA was undertaken, the patient was prepped and draped in sterile fashion.  Appropriate DVT prevention interventions undertaken and perioperative antibiotics were provided.
+We initiated with the breast augmentation with 5 cm incisions after 4 cc of 1% lidocaine with epi injected here.  Scalpel and bovie used to elevate the pec major bilaterally and create pockets for implants.  Copious irrigation undertaken and hemostasis achieved.  On the right, I elevated a portion of the pec minor for 2 cm which I then sutured back down with 2-0 vicryl.  Released portion of the sternal head of pec major bilaterally and performed dual plane to the level of the inferior border of the areola bilaterally with the sizers in place to facilitate.  We first placed the 300 cc sizers on the right and then assessed the 325 on the left.  The 325 cc sizers better approximated her preop photo desires and so we removed the sizers and then irrigated again.  We changed gloves and used a no touch technique with the funnel to place the implants.  Sitting up, the breasts appeared symmetric and thereafter we closed in layers with 3-0 PDS for deep sutures and then 3-0 monocryl for SFS and deep dermals.  4-0 monocryl for skin and then dermabond and telfa with tegaderm.
+We then addressed the abdominoplasty with incision 7.5 cm above labial majora and extending towards the hips.  We dissected down to anterior rectus sheath.  The patient is very slender and great care undertaken to protect the vascularity of the abdominal flap.  She had significant rectus diastasis with the umbilicus nearly entirely attenuated down to the fasia.  There was effectively no umbilical stalk.  We carried the dissection up the costal margins and xiphoid.  Copious irrigation undertaken and then hemostasis achieved.  We undertook rectus plication with 0 neurolon in figure of eight sutures above and below the umbilicus.  We then sat her up and made small adjustments of tightening with the same suture.  We estimated the amount of skin to excise and did so.  We then placed a 10 blake drain out the right side of the incision and secured with 3-0 nylon.  Marked umbilical location and excised an oval.  We placed progressive tension sutures with 2-0 viryl and then inset the umbilicus with 4-0 monocryl from deep dermals down to fascia to approximate the appearance of an "innie."  We then closed the skin over 10 cc of spray thrombin using 3-0 vicryl for SFS and then 3-0 monocryl for deep dermal sutures and 4-0 monocryl for running subcuticular sutures.  Dressing applied and patient maintained in flexed position for transfer.  Abdominal binder and bra placed.
+Needle, sponge and instrument counts were correct at the conclusion of the case.  I was present and scrubbed throughout, performing or directing all key aspects of the case.  There were no complications apparent.  Patient was extubated and transferred to PACU in stable condition.
+</WRAP>
+<WRAP half column>
+Drain: 10 blake secured with 3-0 nylon\\
+Sutures: 2-0 vicryl, 3-0 PDS for deep sutures and then 3-0 monocryl for SFS and deep demals. 4.0 monocryl for skin and then derabond and telfa with tegaderm. Progressive tension sutures with 2-0 viryl and then inset the umbilicus with 4-0 monocryl from deep dermals down to fascia to approximate the appearance of an "innie."  We then closed the skin over 10 cc of spray thrombin using 3-0 vicryl for SFS and then 3-0 monocryl for deep dermal sutures and 4-0 monocryl for running subcuticular sutures.  \\
+Dressing: Abdominal binder and bra placed.\\ ?Dermabond
+</WRAP>
+</WRAP>
 ====Female Feminization====
@@ Line 23: / Line 218: @@
 Take Augmentin for 14 days.
+Facial fem.\\
+N. Pain meds\\
+HEENT. peridex qid. No brushing bottom teeth. \\
+Ice 2 hours on 2 hours off. \\
+Betamethasone to lips prn\\
+GI. POD#0. CLD. After blenderized diet\\
+HEME. SCDs. No chemical ppx.\\
+ID. Unasyn while in house. Augmentin 14 day on discharge. \\
+Okay to remove dressing and shower in 48 hours. \\
 ====Breast Reduction====
+- Almost always uses inferior pedicle (7cm equilateral triangle)
+- Dressing: 1" iodine steri-strips over entire incision
+Steris over vertical and horizontal incisions (hides ugly staple marks)
+====Alveolar Bone Grafting (w/BMP)====
+<WRAP group>
+<WRAP half column>
+The patient was brought to the operating room and placed in supine position on the operating room table. After general endotracheal anesthesia was induced, a weight appropriate dose of ancef was delivered intravenously, and all pressure points were padded. The table was rotated 180 degrees and the face and prospective donor hip were then prepped and draped in standard sterile fashion.
+The alveolar cleft was evaluated and revealed an oronasal fistula as expected. Incisions were marked with a surgical pen along the labial buccal sulcus. The area was then infiltration with 1:100000 epinephrine solution and given 7 minutes to take effect. The planned incisions were then made using a 15 blade scalpel. Using tenotomy scissors, mucosal flaps were raised. Next, the incisions were carried along the tooth margins bordering the alveolar cleft. The mucosae were then reflected into the mouth and extended along the palatal margins- with refection of the mucosa into the mouth. This tissue would be used for palatal closure. Next, the remaining lateral margins of the oronasal fistula were reflected into the nasal floor as far posterior as permitted. This completed full exposure of the outer cortex of the alveolar cleft. Next, the palatal defect was closed by reflecting the mucosal margins into the mouth and approximating them with interrupted 3-0 vicryl. The nasal floor was then reconstructed closing the nasal portion of the oronasal fistula by approximating the nasally reflected fistular margins with interrupted 4-0 vicryl. The repair was tested and found to be water tight.
+BMP and mastergraft were prepared into rolled donors and left to sit for approximately 20-30 minutes.  The graft was brought to the field and advanced into the alveolar cleft, completely filling the void.
+With this completed, the labial mucosae was advanced centrally to close the defect. It appeared a bit tight and therefore the periosteum of the lesser segment was scored vertically and also an oblique vertical cut was made for a gingivoperiosteoplasty, full thickness, to allow the gingiva to rotate mesially.  The buccal sulcus incision was then closed with interrupted horizontal mattress 3-0 vicryl sutures followed by a running horizontal mattress. The mouth was copiously irrigated.
+</WRAP>
+<WRAP half column>
+Post-op care: see preferences below\\
+Pimp Questions:\\
+  * What is the purpose of alveolar bone grafting? To fill in alveolar cleft
+  * When is it done? Mixed dentition phase, meaning there are mixed amounts of permanent and baby teeth. Most importantly, it is prior to eruption of both the lateral incisors and canines. Typically around age 7-8 years old.
+  * What are common harvest sites of bone graft? Iliac crest, rib graft (autologous), BMP (synthetic)
+  * What can cause failure of bone graft? Friction, infection
+  * How do we prevent those things? Maxillary splint, soft pureed diet, antibiotics
+  * What are the stages of bone graft take? Inflammation, osteoblast differentiation, osteoinduction, osteoconduction, remodeling
+</WRAP>
+</WRAP>
-"Dressing: Dermabond over NAC
+=====Cleft Physician Preference=====
-Steris over vertical and horizontal incisions (hides ugly staple marks)"
-====Cleft Physician Preference====
 ====Cleft Lip====
@@ Line 49: / Line 282: @@
 **Follow up	**1 week/then 1 month\\
-**__Cleft Palate	__**\\
+====Cleft Palate====
 **Antibiotics	**intraop\\
@@ Line 73: / Line 306: @@
 **Follow up	**1 wk; 1 month\\
-**__Ear Tubes	__**\\
+====Ear Tubes====
 **Follow up** 	1 month/combo w plas\\
 **Antibiotics	**\\
@@ Line 82: / Line 315: @@
 **Follow up audio**	\\
-**__Pharyngeal Flap	__**\\
+====Pharyngeal Flap====
 **Antibiotics	**intraop\\
 __OTC medications	__\\
@@ Line 89: / Line 322: @@
 **Oxycodone	**yes\\
 **Lortab	**yes\\
-**Diet Restrictions	**blenderized 3 weeks\\
+**Augmentin **Case dependent; typically 24 hours but confirm with Maureen/attending
+**Diet Restrictions	**CLD on POD0, advance as tolerated to blenderized; 3 weeks\\
+**Nutrition consult
+**Scheduled Zofran for nausea control
 **Follow up	**3-4 weeks\\
 **When to resume speech**	1 month\\
-**Activity Restricitons	**restricted x 1 month\\
+**Activity Restrictions	**restricted x 1 month\\
 **? Automatic referral to VPI	**NO\\
 **Length of stay	**1-2 nights, depends on PO/pain\\
-**__Alveolar Bone Graft	__**\\
+====Alveolar Bone Graft====
 **BMP**	                      secondary choice\\
 **Iliac Crest**              	preferred\\