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--- resident:brooke_french [2020/04/29 10:19] – [Female to Male Chest] jonathan
+++ resident:brooke_french [2022/05/24 18:01] (current) – [Breast Reduction] ally
@@ Line 11: / Line 11: @@
 =====Operations=====
-====Female to Male Chest====
+**General Tips:**\\
+Dr. French will ALWAYS ask you questions in OR so be prepared!\\
-<WRAP Group>
+====ORIF Mandible with MMF====
+<WRAP group>
 <WRAP half column>
-Pre/Post Procedure Diagnosis:  Gender dysphoria\\
+Indication: R parasymphyseal mandibular fracture, bilateral mandibular condyle fractures, alveolus lacerations/avulsions, multiple teeth loss 2/2 MVC trauma
-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.\\
+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.
-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.
+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>
 <WRAP half column>
-Drain: No\\
+Prep: Peridex, brush teeth\\
-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\\
+Sutures: 3-0 vicryl for muscle, 4-0 vicryl for mucosa\\
-Dressing: Dermabond and op site dressings applied. Abdominal binder for compression.\\
+Pimp questions: \\
+  * Basic anatomy, location of mental nerve
-Starts with tumescence.\\
+  * Malocclusion types
-Dr. French uses liposuction to obliterate IMF and to thin out the tail of Spence.\\
+  * How many teeth do children have vs. adults? 20 vs. 32
-Hemostasis is critical and she will progressive tension sutures, thrombin, and compression.\\
+  * 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>
-====F to M Mastectomy with Free Nipple Grafting====
+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
+Pre/Post Procedure Diagnosis:  Gender dysphoria\\
-Procedure: Bilateral mastectomy with free nipple/areolar grafts and liposuction flanks and IMF
+Procedure: Bilateral mastectomy with free nipple/areolar grafts and liposuction flanks and IMF\\
-Surgeon:  Brooke French, MD
+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.\\
-Assistant:  Jonathan Freedman, MD resident
+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.
-Anesthesia:  GETA
-EBL:  100 cc
-IVF:  See op note
-Specimen:  Right and left breast tissue
-DOS:  11/7/19
-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.
-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 Blaire preoperatively for excision mastectomy and these marks were confirmed.  We used VASER liposuction and then SAL 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.  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>
-Tourniquet: No\\
+Drain: No\\
-Drain: placed bilaterally and brought out through stab incisions laterally\\
+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\\
-Sutures:  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. \\
+Dressing: Dermabond and op site dressings applied. Abdominal binder for compression.\\
-Dressing: Yes\\
+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====
@@ Line 179: / Line 187: @@
 .  Bilateral breast augmentation silicone 325 cc submuscular dual plane
 .  Abdominoplasty with rectus plication
-Surgeon:  Brooke French, MD
-Assistant:  Jonathan Freedman, MD resident
-Anesthesia:  GETA
-EBL:  150 cc
-IVF:  See op report
-Specimen:  None
-DOS:  November 07, 2019
-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 capsular contracture, mastopexy or need to repair hernia.  All questions have been answered to the best of my ability.
@@ Line 212: / Line 201: @@
 <WRAP half column>
-Tourniquet: No\\
 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:Yes\\
+Dressing: Abdominal binder and bra placed.\\ ?Dermabond
 </WRAP>
@@ Line 229: / Line 217: @@
 Limit your diet to pureed food only.
 Take Augmentin for 14 days.
-====Breast Reduction====
-"Dressing: Dermabond over NAC
-Steris over vertical and horizontal incisions (hides ugly staple marks)"
-=====Cleft Physician Preference=====
 Facial fem.\\
@@ Line 248: / Line 228: @@
 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>
+=====Cleft Physician Preference=====
 ====Cleft Lip====
@@ Line 306: / 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\\