Differences

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--- resident:brooke_french [2021/07/08 08:58] – [Pharyngeal Flap] taylor
+++ resident:brooke_french [2022/05/24 18:01] (current) – [Breast Reduction] ally
@@ Line 11: / Line 11: @@
 =====Operations=====
-General Tips:\\
+**General Tips:**\\
-\\
+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 ====
@@ Line 74: / Line 100: @@
 </WRAP>
 </WRAP>
 ====Scalp Tissue Expander====
@@ Line 209: / Line 229: @@
 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
-"Dressing: Dermabond over NAC
+Steris over vertical and horizontal incisions (hides ugly staple marks)
-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=====
@@ Line 274: / Line 322: @@
 **Oxycodone	**yes\\
 **Lortab	**yes\\
+**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
@@ Line 279: / Line 328: @@
 **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\\