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--- resident:christodoulos_kaoutzanis [2021/07/16 14:15] – ryan
+++ resident:christodoulos_kaoutzanis [2023/10/31 18:26] (current) – [Pedicled ALT Phalloplasty] haley.d
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 =====Intro save=====
@@ Line 6: / Line 5: @@
 =====DIEP Flap ERAS Post-op Protocol=====
+Use Surgical Pathway for orders. Transfuse for Hgb <8.
 [[medical_student:diep_post-op_protocol|Dr. Kaoutzanis' DIEP Post-Op Protocol]]
 =====Operating Reports=====
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 General Tips:\\
 \\
+==== Penis skin graft ====
+Penis irrigation: Drip 30-60cc Sulfamylon solution 2.5% into white sponge every 8 hours. Take down POD5. Bedrest till takedown. Foley out at takedown.
+==== Facial Feminization: frontal bone contouring, brow lift ====
+<WRAP group>
+<WRAP half Column>
+\\
+First, 10 mL of 1% lidocaine with epinephrine was infiltrated into the planned hairline/coronal incision. After allowing adequate time for vasoconstriction, a 15 blade was used to make an incision extending from the anterior aspect of the left auricle to the anterior aspect of the right auricle. Dissection was carried out through subcutaneous tissue to the level of the subgaleal plane posteriorly using electrocautery. The coronal flap was then elevated within the subgaleal plane paying careful attention to stay deep to the superficial layer of the deep temporal fascia. The frontal nerves were visualized, retracted and protected. At that point the frontal bone prominence was visualized. The dissection was transitioned to a subperiosteal plane, and dissection proceeded inferiorly to the supraorbital rims. The supraorbital foramens were identified and the neurovascular bundles going through them were preserved during the case. Of note, both neurovascular bundles were within a bony tunnel and had to be released by removing the inferior piece of bone using an osteotome. At that point, transillumination was used to outline the frontal sinus. A reciprocating saw was then used to remove the anterior table of the frontal sinus in a full thickness fashion. This was delivered without any injury to the posterior table or nasal frontal outflow tracts. Of note, the mucosa along the nasal frontal outflow tracts was preserved bilaterally. The bone was then contoured in the back table with a pineapple bur until the flattened appearance had been achieved. Additional contouring of the frontal bandeau was performed with a pineapple bur. Once the central portion of the frontal bone osteotomy had been contoured appropriately, this was stabilized to the frontal bone with three 4 mm plates using 4 mm self drill screws. Remaining contouring of the frontal bandeau as well as the supraorbital rims was performed with a pineapple bur. Once appropriate contour had been achieved, the frontal bone was copiously irrigated with antibiotic saline solution.
+At that point, it was clear that the radix and dorsum of the nose needed augmentation. Therefore, we decided to harvest a sheet of deep temporal fascia 5 cm x 5 cm from the left side in order to be used with diced cartilage for the augmentation. The area was marked and the the fascia was harvested with electrocautery.
+Next, we proceeded with the hairline advancement and the bilateral brow lift. The coronal flap was elevated posteriorly within the subgaleal plane all the way to the posterior scalp to allow forward advancement. Using electrocautery, several galeotomies every about 2 cm were then performed perpendicular to the plane of advancement. Care was taken not to go too superficial and compromise the vascularity of the skin. At that point we had enough advancement to decrease the forehead length to about 5.5 cm. Once we were satisfied with the advancement the skin edges were tailor tacked with staples, making sure to also advance the coronal flap superiorly at the lateral most extent of the lateral brow bilaterally in order to elevate the brows and correct as much of the preoperative brow ptosis as possible. Excess skin was appropriately excised from the anterior scalp flap, positioning the hairline forward and the brows in an ideal position. The wound was irrigated with antibiotic solution and hemostasis was obtained. A 7-French flat JP drain was placed into the posterior scalp and brought out through a separate stab incision. It was secured in place with a 3-0 Prolene suture. Next, a drill was used and bone tunnels were created within the anterior table just below the edge of the anterior scalp flap in order to allow anchoring of the scalp flap to the bone for a more durable result. Using a 2-0 PDS suture between the galea of the anterior scalp flap and the bone tunnel the flap was anchored to the bone at two different locations, one on each side. Next, the tissues were realigned and approximated in a layered fashion with interrupted 2-0 Vicryl sutures for the subgaleal plane, followed by a few interrupted 3-0 Monocryl sutures for the deep dermis and 3-0 Monocryl Stratafix suture for the subcuticular closure.\\
+</WRAP>
+<WRAP half Column>
+DVT PPX: SQH 5000\\
+Intra-op abx: Ancef\\
+Prep: ETT should be directed caudally. Rotate bed 180 degrees. Shave hair over incision marking (but not anterior sideburns). Betadine to face + ophthalmic betadine. Pull hair back with rubber bands. Sterile placement of corneal shields. Sterile injection of Lidocaine 1% w/ epi along bicoronal markings.\\
+Sutures: Drain stitch (3-0 Prolen), brow lift (2-0 PDS), subgaleal closure (2-0 Vicryl), deep dermis (3-0 Mono), subcuticular (3-0 Mono Stratafix)\\
+Drains: 1x JP drain exiting through incision\\
+Relevant anatomy: facial nerve, temporoparietal fascia, supraorbital foramen, frontalis muscle, innervation/blood supply to scalp, nasofrontal ducts and frontal sinus, anterior/posterior tables of frontal sinus\\
+Markings and Shaving:\\
+{{:resident:ff1.jpg?400|}}
+Frontal sinus exposure:\\
+{{:resident:ff2.jpg?400|}}
+Anterior table plating:\\
+{{:resident:ff4.jpg?400|}}
+Dressing:\\
+{{:resident:ff5.jpg?400|}}
+</WRAP>
+</WRAP>
+==== Facial Feminization: Genioplasty, bilateral contouring of mandibular angles====
+<WRAP group>
+<WRAP half Column>
+Our attention was directed to the mandibular angles. Approximately 5 mL of 1% lidocaine with epinephrine was infiltrated into the confines of the intraoral incisions. After allowing adequate time for hemostasis anesthesia, a 15 blade was used to make an incision along the right external oblique ridge. Dissection was carried out sharply with electrocautery until visualizing the mandible. A #9 periosteal elevator was used to elevate the periosteum and the masseter muscle from the posterior body and angle of the mandible. I was then able to visualize the prominent posterolateral aspect of the body as well as the mandibular angle. This was contoured carefully with a Sonopet iQ micro claw until appropriate contour had been achieved. I then directed my attention to the contralateral left side where a similar procedure was performed. A 15 blade was used to make an incision along the left external oblique ridge. Dissection was carried out sharply with electrocautery until visualizing the mandible. A #9 periosteal elevator was used to elevate the periosteum and the masseter muscle from the posterior body and angle of the mandible. I was then able to visualize the prominent posterolateral aspect of the body as well as the mandibular angle. This was contoured carefully with a Sonopet iQ micro claw until appropriate contour had been achieved. Both wounds were copiously irrigated with normal saline and hemostasis was confirmed. Symmetry was also confirmed. The incisions were then closed with 3-0 chromic gut suture in a running fashion at the myomucosal level.
+Our attention was then turned to the chin to perform the genioplasty. The lower lip was stretched outward to allow visualization of the mental nerves through the mucosa and an incision was planned between the visible nerves. Approximately 5 mL of 1% lidocaine with epinephrine was infiltrated into the confines of the intraoral incision. A 15 blade was used to make an incision along the gingivobuccal sulcus. Electrocautery was then used to dissect through the mucosa and mentalis muscle leaving at least a 1-cm cuff of mucosa and muscle to allow easy closure after the procedure. Dissection continued with a periosteal elevator in a subperiosteal plane laterally on both sides to identify the mental foramen and neurovascular bundle, as well as inferiorly to expose the anterior surface of the chin. Great care was taken throughout the procedure to keep the mental nerves intact. We also ensured that some of the mentalis muscle remained attached to the anterior aspect of the mandible. The central and inferior aspects of the central mandible were very prominent and they were thus taken down conservatively with a pear bur. Then, we marked the location of the horizontal osteotomy, ensuring it was at least 5 mm below the apices of the canine teeth and 6 mm below both mental foramens. Then, two vertical osteotomy lines were designed perpendicular to the horizontal osteotomy line. In this case, the width of the central chin narrowing portion was determined to be 1.2 cm. The midline was also marked between the incisors to ensure proper alignment during plating. A reciprocating saw was used to complete the horizontal osteotomy and the two vertical osteotomies that resulted in removal of a central bone segment. The remaining two lateral bone segments were then brought to the midline and secured to the superior aspect of the remaining mandible with a 0.7 mm titanium X-plate using 12 mm screws. Another 0.5 mm titanium curve plate with 3 holes was used to secure the right lateral bone segment to the superior aspect of the mandible. The plate was contoured and secured in place using 10 mm screws. Also, a 0.5 mm titanium curve plate with 3 holes was used to secure the left lateral bone segment to the superior aspect of the mandible. The plate was contoured and secured in place using 10 mm screws. Good bone-to-bone contact was noted after plating was completed. We did not feel that anterior advancement or posterior setback of the chin was needed in this case. However, narrowing of the chin left a bony step on each side of the chin-mandible junction, and this discontinuity was eliminated and appropriately contoured using a Sonopet iQ micro claw. At that point we were satisfied with the result. The wound was copiously irrigated with normal saline and hemostasis was confirmed. Symmetry was also confirmed. The mentalis muscle was re-approximated with several interrupted 3-0 Vicryl sutures. The mucosal incision was then closed with 3-0 Chromic gut suture in a running fashion.
+</WRAP>
+<WRAP half Column>
+Prep: peridex-soaked throat packing\\
+Sutures: intra-oral mucosa (3-0 Chromic gut), mentalis muscle re-approximation (3-0 Vicryl)\\
+Dressing: None\\
+Postoperative care: CLD x48h, liquid diet x48h, blended diet x4wks; peridex qid, abx x7d, avoid strenuous activity for 4 weeks \\
+Relevant anatomy: mental nerve/foramen, masseter, mentalis; mandibular incision needs to be made __6mm__ below the mental nerve\\
+{{:resident:img_6870.jpeg?400|}}
+</WRAP>
+</WRAP>
+==== Septorhinoplasty: Septal strut, columellar strut, spreader grafts, interdomal sutures, transdomal sutures, temporoparietal fascia graft to dorsum, alar rim resection ====
+<WRAP group>
+<WRAP half Column>
+\\
+Our attention was then directed to the nasal region. After appropriate markings were completed, the nose was injected with 1% lidocaine with epinephrine for a total of 8 mL. The nasal vestibule was packed with Afrin-soaked cottonoids. After allowing adequate time for vasoconstriction, bilateral marginal incisions were created and connected to a curved inverted-V transcolumellar incision. The soft tissues were elevated off the cartilaginous framework. This dissection proceeded along the nasal dorsum and nasal pyramid until arriving cephalad to the nasal radix. The dissection was also extended laterally to the piriform rim bilaterally. At this point, I had complete visibility of the lower lateral cartilages, upper lateral cartilages and the nasal bone. The medial crura of the lower lateral cartilages were flaring partially and the lower lateral cartilages had abnormal shape. No dorsal reduction was needed, but augmentation of the dorsum and radix was felt necessary. The Afrin-soaked cottonoids were removed and accounted for. The anterior septal angle was identified and the mucoperichondrium was elevated off both sides of the nasal septum taking care to avoid any perforations. We did have a perforation on the right that was recognized and repaired with 4-0 Chromic sutures. This was followed by separation of components to access to cartilaginous dorsum. Both upper lateral cartilages were separated completely from the dorsal septum leaving the mucosa intact. The caudal aspect of the septum was slightly curved and thus resected down to the anterior nasal spine with scissors. Then, the septal cartilage was removed leaving 10 mm L-strut which was measured with callipers. A small amount of the caudal aspect of the vomer bone was protruding into the right nostril, thus it was carefully removed to relieve some of the nasal obstruction. Lateral osteotomies were performed next to address the open roof deformity and the wide nasal bones. These were done as low to low continuous osteotomies intranasally, taking care to preserve websters triangle bilaterally. A single guarded osteotome was placed at the piriform rim and a mallet was used to complete the osteotomy extending to the level of the medial canthus bilaterally. A 2 mm osteotome was then used percutaneously to extend the osteotomy to the nasal radix bilaterally. The nasal bones were then infractured to close the open roof deformity and narrow the overall nasal width. It was felt that a double-level osteotomy was needed bilaterally at that point given the persistent convexity of the lateral wall mostly on the right, and thus completed along the inferior border of the nasal bone parallel to the low-to-low osteotomy using a  2 mm osteotome percutaneously. Since the septal graft that was harvested was not long enough, I elected to use cadaveric costal cartilage for some of the grafts. A septal extension graft was then carved to the desired dimensions from the cadaveric costal cartilage and placed along the caudal aspect of the septum, and secured to it with several 5-0 PDS sutures in a horizontal mattress fashion, and was positioned 6 mm above the anterior septal angle. At that point it was felt that a left spreader graft was necessary to improve the patency of the internal nasal valve. Part of the cadaveric costal cartilage was used to fashion the thin spreader graft for the left side. The spreader graft was then placed along the dorsal aspect of the L-strut and secured to the septum with several 5-0 PDS sutures in a horizontal mattress fashion. The dorsum was then closed by approximating the upper lateral cartilages over the dorsal septum with a few interrupted 5-0 PDS sutures. Our attention was then turned to the augmentation of the radix and dorsum using diced cartilage from the cadaveric costal cartilage and the already harvested deep temporal fascia. The cartilage was diced to 0.5 mm cubes and then placed in fascia which was sutured together with 4–0 plain catgut. The construct was “made to measure” on the back table and guided into the dorsal pocket using percutaneous 4-0 Chromic sutures on the cephalad aspect. A small amount of excess cartilage was milked out at the caudal end and then the graft was closed using 4–0 plain catgut, and secured to the cartilaginous dorsum using 5-0 PDS sutures. Our attention was then turned to the nasal tip that had to be restored since most of the ligamentous attachments were released due to the open nature of the rhinoplasty. We ensured that the lower lateral cartilages were completely freed from the underlying mucosa to the medial crus on both the right and left sides to allow caudal displacement and achieve a good nasal shape.  The low lower cartilage was then infiltrated with 0.5 mL of 1% lidocaine with epinephrine, and a cephalic trim preserving 6 mm of lower lateral cartilage in width was performed bilaterally. The septal extension graft was not extending all the way to the columella and the medial crura of the lower lateral cartilages were still somewhat curved so we decided to placed a columellar strut. It was carved to the desired dimensions from the cadaveric costal cartilage and placed in a subcutaneous pocket in the base of the columella without touching the anterior nasal spine. The columellar strut was secured in place between the middle and medial crura of the lower lateral cartilages with interrupted buried 5-0 PDS sutures. Transdomal sutures were then placed in the tip bilaterally to define the lower lateral cartilages. These were followed by caudal interdomal sutures to decrease the width of the tip. Then a domal equalization suture was placed on the cephalad aspect of the lower lateral cartilages to bring them together and restore symmetry. All tip sutures were completed with 5-0 PDS. At that point we had achieved appropriate nasal tip shape, projection, and support. Alar rim grafts were then carved to the desired dimensions from the previously harvested septal cartilage in order to support the patency of the external nasal valves. A subcutaneous pocket was created from cephalad to caudal paralleling the alar rim bilaterally. The alar rim graft was slipped into the pocket bilaterally. The cephalic end of the graft was trimmed to avoid palpability and distortion of the soft tissue facet. The wound was irrigated with normal saline solution, and hemostasis was confirmed. The skin was then closed with interrupted 5-0 Nylon sutures at the columella and interrupted 4-0 Chromic gut sutures intranasally. The soft triangles were not approximated with sutures but packed with bacitracin-soaked Surgicel sheet. At that point attention was turned to the alar bases. Alar flaring with anterior nostril show was obvious bilaterally requiring combined nostril sill excision and alar wedge excision. The area of resection was marked bilaterally prior to infiltrating 0.5 mL of 1% lidocaine with epinephrine. We designed the lower portion of the alar wedge excision around to the medial vertical wall of the nostril sill excision. Using the calipers we determined the sill width component and the height of the alar wedge component that was about 5 mm on the right and 6 mm on the left. We ensured symmetry between the two sides. Using a 15 blade the vertical sills were cut first followed by alar wedge incisions. Hemostasis was confirmed. The sill was approximated first with 4-0 Chromic sutures in a horizontal mattress fashion bilaterally. The alar incision was then approximated with interrupted 5-0 Nylon sutures on both sides.
+All incisions were copiously irrigated with saline. The eyes were irrigated with balanced salt solution. Steristrips were then placed over the nasal dorsum after a proper skin preparation followed by a Denver nasal splint. Doyle splints lubricated with bacitracin ointment were also inserted in both nostrils and sutured together to compress the mucosal leaflets with a single horizontal mattress suture of 3–0 Prolene through the septum. Bacitracin was applied to the external nasal incisions followed by a drip pad. The hair was washed with shampoo and conditioner. The scalp incision was dressed with Bacitracin and Xeroform. A compressive dressing consisting of 4 x 8s and Kerlix were placed over the scalp.
+</WRAP>
+<WRAP half Column>
+Sutures: XX\\
+Drains: None\\
+Dressing: XX\\
+</WRAP>
+</WRAP>
 ==== Parascapular Flap ====
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 Resident Notes:\\
+{{:resident:img_9436.jpg?400|}}
 </WRAP>
 </WRAP>
@@ Line 201: / Line 284: @@
 The patient was taken to the operating room, and placed supine on the operating room table. SCDs were placed onto the lower extremities for DVT prophylaxis. Ancef was administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. After successful smooth induction of general anesthesia, a surgical time out was performed, and the patient's identification, site, and procedure were verified. The chest and upper abdomen were prepped and draped in the usual sterile fashion. \\
-We began by excising the nipple-areolar complex on the right and the left as full-thickness grafts (2.2 x 2.2 cm circle) and handed them off to the back table. I then turned my attention to the right side where the upper breast incision was made using the 10 blade. The dissection was carried down to the plane between the breast parenchyma and the subcutaneous fat using electrocautery. The dissection was then carried cephalad and laterally creating a superior mastectomy flap. Care was taken to dissect over the axillary tail and include all breast tissue in the specimen. The breast tissue was then elevated off of the pectoralis muscle taking care to preserve the overlying fascia. The superior mastectomy flap was pulled down and the ability to close primarily was then confirmed. An inferior incision was made. Again, the dissection was carried out inferiorly in the plane between the breast parenchyma and the subcutaneous tissue, creating an inferior flap. The breast tissue was dissected free and sent off to pathology for analysis.  Care was taken to undermine the inferior flap beyond the inframammary fold to obliterate it. The cavity was copiously irrigated and hemostasis was confirmed.  The incision was then reapproximated and this was repeated on the left side. The upper breast incision was made using the 10 blade. The dissection was carried down to the plane between the breast parenchyma and the subcutaneous fat using electrocautery. The dissection was then carried cephalad and laterally creating a superior mastectomy flap. Care was taken to dissect over the axillary tail and include all breast tissue in the specimen. The breast tissue was then elevated off of the pectoralis muscle taking care to preserve the overlying fascia. The superior mastectomy flap was pulled down and the ability to close primarily was then confirmed. An inferior incision was made. Again, the dissection was carried out inferiorly in the plane between the breast parenchyma and the subcutaneous tissue, creating an inferior flap. The breast tissue was dissected free and sent off to pathology for analysis.  Care was taken to undermine the inferior flap beyond the inframammary fold to obliterate it. The cavity was copiously irrigated and hemostasis was confirmed. The incision was then approximated. The patient was brought up into the seated position to confirm symmetry as well as nipple position. The new nipple-areolar complex was placed 1 cm above the incision and 2 cm from the lateral pectoral border. The patient was brought back down into the supine position. A 15-French round Jackson Pratt drain was placed on both the right and the left and secured with 3.0 nylon suture. The incisions were approximated with a few three way 2-0 Vicryl sutures between the breast flaps and pectoralis major muscle to ensure that the incision will not migrate. The incisions were then further approximated with interrupted 3-0 Monocryl sutures for the deep dermis, followed by a running subcuticular 3-0 Monocryl Stratafix suture. A 2.2 x 2.2 cm circle on the superior mastectomy flap was then de-epithelialized on both the right and the left. The nipple-areolar complexes, which had been removed earlier as full-thickness skin grafts, were then thinned and placed back on the chest wall and sutured into place using half buried running 5-0 chromic suture. In addition, single interrupted 5-0 chromic sutures were placed at 3, 6, 9, and 12 o’clock around the nipple for quilting of the nipple-areolar complex and better definition of the nipple. A bolster dressing was placed on the nipple-areolar complex grafts including cotton balls soaked in mineral oil wrapped with xeroform and secured with 3-0 Monocryl sutures and tegaderm. Mastisol and steristrips were used as dressings for the breast incisions. Biopatches and tegaderms were used as dressings for the JP drain sites. Foam was applied over the breasts and the patient was then placed in a chest compression vest.\\
+We began by excising the nipple-areolar complex on the right and the left as full-thickness grafts (2.2 x 2.2 cm circle) and handed them off to the back table. I then turned my attention to the right side where the upper breast incision was made using the 10 blade. The dissection was carried down to the plane between the breast parenchyma and the subcutaneous fat using electrocautery. The dissection was then carried cephalad and laterally creating a superior mastectomy flap. Care was taken to dissect over the axillary tail and include all breast tissue in the specimen. The breast tissue was then elevated off of the pectoralis muscle taking care to preserve the overlying fascia. The superior mastectomy flap was pulled down and the ability to close primarily was then confirmed. An inferior incision was made. Again, the dissection was carried out inferiorly in the plane between the breast parenchyma and the subcutaneous tissue, creating an inferior flap. The breast tissue was dissected free and sent off to pathology for analysis.  Care was taken to undermine the inferior flap beyond the inframammary fold to obliterate it. The cavity was copiously irrigated and hemostasis was confirmed.  The incision was then reapproximated and this was repeated on the left side. The upper breast incision was made using the 10 blade. The dissection was carried down to the plane between the breast parenchyma and the subcutaneous fat using electrocautery. The dissection was then carried cephalad and laterally creating a superior mastectomy flap. Care was taken to dissect over the axillary tail and include all breast tissue in the specimen. The breast tissue was then elevated off of the pectoralis muscle taking care to preserve the overlying fascia. The superior mastectomy flap was pulled down and the ability to close primarily was then confirmed. An inferior incision was made. Again, the dissection was carried out inferiorly in the plane between the breast parenchyma and the subcutaneous tissue, creating an inferior flap. The breast tissue was dissected free and sent off to pathology for analysis.  Care was taken to undermine the inferior flap beyond the inframammary fold to obliterate it. The cavity was copiously irrigated and hemostasis was confirmed. The incision was then approximated. The patient was brought up into the seated position to confirm symmetry as well as nipple position. The new nipple-areolar complex was placed 1 cm above the incision and 2 cm from the lateral pectoral border. The patient was brought back down into the supine position. A 15-French round Jackson Pratt drain was placed on both the right and the left and secured with 3.0 nylon suture. The incisions were approximated with a few three way 2-0 Vicryl sutures between the breast flaps and pectoralis major muscle to ensure that the incision will not migrate. The incisions were then further approximated with interrupted 3-0 Monocryl sutures for the deep dermis, followed by a running subcuticular 3-0 Monocryl Stratafix suture. A 2.2 x 2.2 cm circle on the superior mastectomy flap was then de-epithelialized on both the right and the left. The nipple-areolar complexes, which had been removed earlier as full-thickness skin grafts, were then thinned and placed back on the chest wall and sutured into place using half buried running 5-0 chromic suture. In addition, single interrupted 5-0 chromic sutures were placed at 3, 6, 9, and 12 o’clock around the nipple for quilting of the nipple-areolar complex and better definition of the nipple. A bolster dressing was placed on the nipple-areolar complex grafts including 2-3 cotton balls moistened in saline wrapped with xeroform (large sheet cut in half made into dumpling) and tegaderm. Dermabond used as dressings for the breast incisions. Biopatches and tegaderms were used as dressings for the JP drain sites. Foam was applied over the breasts and the patient was then placed in a chest compression vest.\\
 </WRAP>
@@ Line 208: / Line 291: @@
 Drain: 15F JP x2\\
 Sutures: Yes\\
-Dressing: Bolster dressing supplies: mineral oil, cotton balls, xeroform \\
+Dressing: Bolster dressing supplies: 2-3x saline moistened cotton balls, xeroform (cut large sheet in half) \\
-Mastisol, steri strips (lg & small), Fluffs, foam surgical bra\\
+Dermabond, ABD pads, vest
 **Have in OR**: \\
@@ Line 216: / Line 299: @@
 -Usually dc home from PACU \\
 -Multiple surgical pens (2-3) \\
--Large pieces of flat foam & surgical bra \\
+-For prepping: Arms out in T & wrapped w/ kerlex. Prep umbo to chin. Blue towels, then ioban. Arm sleeves and then bottom & top sheet. Then side sheets. He likes the pouches for instruments with the hard containers. \\
--For prepping: Arms out in T & wrapped w/ kerlex. Prep umbo to chin. Blue towels, then ioban. Arm sleeves and then bottom & top sheet. Then side sheets. He likes the pouches for instruments, not the hard containers. \\
 </WRAP>
@@ Line 316: / Line 398: @@
 {{ :resident:img_8242.jpg?200 |}}
+Tourniquet: N/A\\
+Drain: 7 French flat JP\\
+Sutures: 2-0 vicryl for subgaleal plane. 3-0 monocryl deep dermals. 4-0 monocryl subcuticular. Drain with 3-0 nylon suture\\
+Dressing: Head Wrap Dressing\\
 Anatomy: Scalp layers and when to transition to sub-periosteal plane, where facial nerve will be found, complications from damage to facial nerve, distance from hairline to brow in female
@@ Line 324: / Line 410: @@
 - HOB elevated to 30 degrees\\
 - Team takes down headwrap POD1, re-dress\\
-- Typically continues abx in-house, okay for ppx ACT\\
+- Typically continues abx in-house, okay for DVT ppx\\
 </WRAP>
 </WRAP>
 ==== Pedicled ALT Phalloplasty ====
@@ Line 373: / Line 461: @@
 Dressing: Kerlix fluffs and tap to keep penis up and not dependent; vac to donor site\\
-Anatomy: Vaginal nerves; ALT anatomy\\
+**Anatomy:**
+Review the Vaginal nerves; and ALT anatomy. Understand which nerves are going to be co-apted and which veins are taken with the ALT to maximize drainage. The ALT donor site is too big for direct closure and is closed with a skin graft.\\
-Post-operative care:
+**Post-operative care:**
-- Bedrest for 48hours post op
+  * Bedrest for 48hours post op
-- please keep phallus in neutral position on kerlix tower, replace kerlix PRN for soilage
+  * please keep phallus in neutral position on kerlix tower, replace kerlix PRN for soilage
-- xeroform dressing placed in distal tip of phallus
+  * xeroform dressing placed in distal tip of phallus
-- strict I's and O's
+  * strict I's and O's
-- foley in place until POD3\\
+  * foley in place until POD3
 Attending Pearls (Learning points/Pimp Questions):\\
+The tunnel needs to be wide as to not compress the flap.\\
+Make sure you understand the coaptations for the nerves.\\
+The surgery usually happens with a second stage to connect the neourethrea. A small opening will be made that needs to be flushes.\\
+The tip can become congested.\\
 </WRAP>
 </WRAP>
+==== Radial Forearm Phalloplasty ====
+{{ :resident:template_for_rfff_phalloplasty.pdf |}}
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
 ==== BBL ====
@@ Line 501: / Line 606: @@
 \\
 The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. Of note, the patient was repositioned from lithotomy every 3 hours, and positioning was rechecked each time. The bladder was intermittently drained. No hematuria was noted. All counts were correct at the end of the case. Dr. Higuchi's assistance was critical to the successful completion of this surgery because of the significantly increased complexity. No qualified residents were available to assist with this technically demanding operation.
+Penile Inversion Vaginoplasty (Full Depth) Description Of The Procedure:
+The patient was taken to the operating room and positioned supine on the operating room table. Sequential compression devices were placed on both lower extremities for mechanical VTE prophylaxis. Heparin 5,000 units was administered subcutaneously for chemical VTE prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. After induction of general anesthesia, a timeout was performed with the entire team. The patient was placed in lithotomy in yellowfin stir-ups well padded. The arms were tucked. All bony prominences and pressure points were well padded. Markings were made. The abdomen, genitalia and perineum were prepped and draped in the usual sterile fashion. An 16 French Foley catheter was placed on the table in sterile fashion, and the bladder drained.
+First, a 2 cm wide by 3 cm long rhomboid flap was designed in the perineum, with the ischial tuberosities and the tip at the perineal scrotal junction as landmarks for the base of the flap. The skin of the rhomboid flap was incised with a 10 blade, and using electrocautery the perineal flap composed of skin and fat was elevated down to the bulbar urethra. Then, the scrotal skin from the base of the penis to the perineo-scrotal junction was excised leaving the tunica vaginalis intact. The remaining tunica vaginalis became incorporated into the soft tissue of the labia later. The scrotal skin was kept on the back table to be used later for vaginal reconstruction. Using a 15 blade, an incision was then made in the midline of the scrotum and along the ventral side of the penis. A circumferential incision in the penile shaft skin was also made 2 cm below the corona of the glans. This excess skin from the shaft was later used for the clitoral hood. A clamp was placed on the glans, and the penis was degloved in the plane of Buck’s fascia creating a flap that would be used to line the vulva and create labia minora. Care was taken not to injure the neurovascular bundle.
+We then proceeded with the bilateral orchiectomy. The tunica vaginalis was opened with electrocautery over the left testicle.  The right testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The right spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was found to have a right inguinal hernia that we repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 0 Prolene sutures in a figure-of-eight fashion. Then, a similar procedure was performed for the left testicle. The tunica vaginalis was opened with electrocautery over the left testicle.  The left testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The left spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was found to have a left inguinal hernia that we repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 0 Prolene sutures in a figure-of-eight fashion.
+The ischiocavernosus muscle and bulbospongiosus muscle were then dissected free from the corpora and bulb, and excised with electrocautery. Next, the urethra was elevated above the tunica albuginea of the corpora cavernosum and freed from the corpora cavernosum distally. Penectomy was then performed. The tunica albuginea was incised on the ventral side on the right and left exposing the corporal tissue. A Yankauer suction tip was used to dissect the entire corpora down to the ischium bilaterally. The corporal tissue was elevated off of the tunica with a freer elevator down to the ischium bilaterally. Care was taken to ligate the corporal vessel at the base bilaterally. The proximal base of the corpora were over sewn with a 4-0 PDS running locking suture bilaterally. Care was taken to preserve the neurovascular bundles at 10 o’clock and 2 o’clock.
+At that point, the bulb was reduced and it was plicated using 3-0 PDS sutures. The perineal portion of the vaginal canal creation was done.  The central tendon of the bulbar urethra was incised. The bulbar urethra was elevated away from the rectum up to the urogenital diaphragm.
+Next, the urethra was amputated at the level of the adductor tendon. A vertical incision was made along the ventral aspect of urethra. The urethra was then opened and widely spatulated to the level of the bulb. The excess urethra was then used to line the vulva and the space between the neoclitoris and the urethral meatus.  The urethra was then everted and rosebuded from the 3 to 9 o'clock position with 4-0 PDS sutures.
+The clitoroplasty was then performed. The glans was split on the ventral surface through the urethra to splay open the glans. The central tip of the glans was excised and the remaining glans was thinned on the ventral surface using scissors. The 4 cm long and 1 cm wide remaining glans was then shaped into a clitoris. Horizontal mattress sutures (tunica-skin skin-tunica) were placed between the limbs half way down, bringing the limbs together. A second row of horizontal mattress sutures was placed in the clitoris to create a ridge. A cuff of penile shaft skin served as the clitoral hood.
+Using adjacent tissue transfer, the penile flap measuring 10 cm x 7 cm was then further undermined past the mons with electrocautery. The fat on the mons centrally over the symphysis was cleared with electrocautery. The tunica of the neurovascular bundle was pexied to the mons pubis with interrupted 3-0 Vicryl sutures so that the clitoris was at the level of the adductor. The limbs of the neoclitoris were sutured to the edges of the vulvar lining/urethral mucosa with interrupted 3-0 Vicryl sutures at the base and running 4-0 Chromic sutures on the sides. The rhomboid flap of the perineum was sutured to the floor of the posterior vagina with interrupted 3-0 Vicryl sutures.
+Next robotic assistance was utilized to create the vaginal canal.  First, the robotic ports were placed and the abdomen was insufflated taking care not to injure the intraabdominal organs. Five robotic ports were placed, 1 in the central upper abdomen and 4 ports in a line with that.  The abdomen was inspected with the camera and no injuries were found. We opened the peritoneum right underneath the seminal vesicles. We identified the seminal vesicles and then identified the Denonvilliers fascia. We separated Denonvilliers fascia to develop a space underneath the prostate and between the prostate and rectum.  We worked our way towards the perineal incision while staying above the rectum.  We eventually were able to palpate the robotic instruments through the perineal area. We then connected the 2 incisions from the perineal area. After these incisions were connected, we started to widen the space robotically to be able to place 4 fingers into the vaginal canal.  A peritoneal flap (7 cm x 6 cm) from anterior rectum and posterior bladder were harvested for the colporrhaphy. The excess scrotal skin was then thinned and prepared as a full thickness skin graft 8 cm x 15 cm to line the vagina. It was sewn together over the 35 mm dilator first with interrupted 3-0 Vicryl sutures followed by a running 3-0 Monocryl suture. The graft was then sutured to the penile flap using two layers, first with interrupted 3-0 Vicryl sutures and then running 3-0 Monocryl suture. At that point, Acell MicroMatrix 1000 mg was applied as powder to all the wound surfaces to assist with healing. The penile flap with the incorporated skin graft was then pulled down towards the perineum and into the canal and delivered into the vaginal canal that had been dissected with robotic assistance. The skin tube was then delivered into the canal to be sutured to the peritoneal flaps. It was clear that the penile flap was too short and some of the skin graft would be part of the external genitalia. The midline of the penile flap / skin graft construct was then marked.  An incision in the midline was made in the construct from the clitoral hood to the base of the urethral meatus. The construct was then sutured to the clitoral hood and urethral mucosa with running 4-0 Chromic sutures.  Scrotal skin flaps were then elevated laterally bilaterally and used to create the labia majora. The majority of the scrotal skin was previously excised leaving the tunica vaginalis behind. The tunica became the soft tissue of the labia. Some of it had to be excised bilaterally. The rest tunica fat was tucked in and the outer edge of the labia majora was then approximated to the inner edge of the remaining scrotal skin on each side with interrupted 3-0 Vicryl sutures for the deep dermis followed by a running subcuticular 3-0 Monocryl Stratafix suture bilaterally. The lateral aspect of the rhomboid flap of the perineum was sutured to the penile skin flap laterally with interrupted 3-0 Vicryl sutures. There was some excess tissue along the central aspect of the neolabia majora bilaterally and that was tailor tacked with staples for our planned resection. Once satisfied with the appearance it was marked bilaterally, the staples were removed, and the skin was excised with scissors. Hemostasis was obtained. Both wounds were approximated with interrupted 3-0 Vicryl sutures for the deep dermis followed by a running subcuticular 3-0 Monocryl Stratafix suture. The labia minora were then further defined by using horizontal mattress 3-0 Monocryl sutures between the medial skin and the neovulva on both sides from the level of the neoclitoris all the way down to just above the urethral meatus. While doing that, robotic assisted laparoscopic abdominal colpopexy was performed to fix the vagina into the proper position between the bladder and rectum. The anterior portion of the neovagina was reapproximated to the anterior leaf of the Denonvilliers fascia using 3-0 V-Loc suture in a running manner. The posterior aspect of the neovagina was fixed to the peritoneal reflection overlying the rectum. After this was done, the anterior and posterior leaves of the peritoneal flap were reapproximated robotically using running 3-0 V-Loc suture for closure of the neovagina. The canal was packed with antibiotic soaked Kerlix packing. The apex of the neovagina was visualized laparoscopically to confirm that the packing went all the way up to the apex. The ports were removed and the port sites were then closed. The deep dermis was approximated with interrupted 3-0 Monocryl sutures and the skin was approximated with 4-0 Monocryl suture in a subcuticular manner for all the abdominal incisions.
+The abdominal, genital and perineal skin was cleansed with normal saline. Dermabond was applied to the abdominal incisions. A wound vac was placed on the vulva and perineum over the Kerlix vaginal packing, and then connected to 125 mmHg of continuous suction without any detectable leaks.  The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. Of note, the patient was repositioned from lithotomy every 3 hours, and positioning was rechecked each time. The bladder was intermittently drained. No hematuria was noted. All counts were correct at the end of the case. Both myself and Dr. Higuchi were present for all the critical portions of this procedure.  Dr.
 \\
 </WRAP>
@@ Line 506: / Line 634: @@
 <WRAP half column>
-Photos\\
+Drain: Wound Vac cut into filleted J and wrapped with adaptic and Foley\\
-{{:resident:865298eb-541e-489a-9435-67c2303c3760.jpeg?400|}}
-Tourniquet: Not used\\
-Drain: Wound Vac cut into fileted J and wrapped with adaptic and Foley\\
 Sutures: Drain stitches: 2-0 nylons\\
-Dressing: wound vacuum as above\\
+Dressing: Wound vacuum as above\\
 Anatomy: Pertinent anatomy should be listed\\
 Post-operative care:\\
-- Vaginoplast pathway - USE SURGICAL PATHWAYS AND VAGINOPLASTY SMART SET\\
+- Vaginoplasty pathway - USE SURGICAL PATHWAYS AND VAGINOPLASTY SMART SET\\
+- Restrictions: bedrest 48 hours, shuffle gait and no abduction more than 20 degrees; should not sit at home\\
 Learning points/Pimp Questions:\\
+Markings:\\
+{{:resident:865298eb-541e-489a-9435-67c2303c3760.jpeg?400|}}
+WV:\\
+{{:resident:vagwv.jpeg?400|}}
+{{:resident:vagwv2.jpeg?400|}}
 </WRAP>
 </WRAP>
+==== Goldilocks Breast Recon ====
+<WRAP group>
+<WRAP half column>
+Operation Titles:\\
+. Immediate first stage reconstruction of the bilateral breasts with a tissue expander (Sientra Dermaspan LPP-FH14S --> Right SN 22D0572-19; Left SN 22D0572-20).\\
+. Bilateral inferiorly-based vascularized dermal flap local tissue rearrangement for lower pole and central coverage in breast reconstruction; right 18 cm x 12 cm and left 17 cm x 11 cm.\\
+. SPY Indocyanine green fluorescence angiography to evaluate the perfusion of the mastectomy flaps bilaterally.
+. Debridement of right mastectomy skin flap, total length 10 cm. \\
+Due to the additional extensive length of surgery required by this technique with the inferiorly-based vascularized dermal flap local tissue rearrangement over and above typical tissue expander reconstruction and in accordance with the recommendations from the American Association of Physician coding, a 22 modifier will be added to the tissue expander reconstruction in addition to the tissue expander reconstruction for bilateral, which would carry a 50 modifier.\\
+Operative Report:\\
+The patient was taken to the operating room and positioned supine on the operating table. Sequential compression devices were placed on both lower extremities for DVT prophylaxis. Heparin 5000 units was administered subcutaneously for chemical DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. All bony prominences were padded. After induction of general anesthesia, the chest area was prepped and draped in the usual sterile fashion.\\
+Please refer to Dr. Tevis' operative note for full details of the bilateral skin sparing mastectomies and right sentinel lymph node biopsy.\\
+At the time that I was called into the operating room, the mastectomies had been completed. The chest was reprepped and redraped and a new clean set of instruments was used for our part.  I proceeded with first stage tissue-expander reconstruction. The mastectomy skin flaps were of uniform thickness, appeared pink and viable. The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines in order to evaluate the viability of the breast flaps.  The breast flaps perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise except the lateral and medial vertical limbs of the right mastectomy flap that were trimmed back to healthy bleeding tissue. Based on the above assessment and the rest of the patient's criteria I felt that prepectoral placement of the tissue expanders was appropriate. Given the thickness of the upper mastectomy skin flaps I felt that there was no need for acellular dermal matrix but only use inferiorly-based vascularized dermal flaps.\\
+We began with the right side. We irrigated the breast pocket with half strength Betadine solution. An 18 x 12 cm inferiorly-based vascularized dermal flap was marked out based on the previously marked Wise pattern and this was deepithelialized. Hemostasis was achieved. The footprint of the breast and tissue expander were confirmed on the skin markings and on the pectoralis major muscle.  Based on the pocket's dimensions we selected a Sientra Dermaspan LPP-FH14S tissue expander with a 14 cm base diameter. The pocket was again irrigated with half strength Betadine and the skin was prepped with betadine.  Gloves were exchanged and the selected tissue expander was placed into the pocket. Prior to doing that the air was removed from the tissue expander, and it was filled with 250 cc of air. The tissue expander tabs were sutured to the chest wall with interrupted 2-0 Vicryl sutures, and we ensured that it was positioned along the lateral border of the breast and inferiorly along the inframammary fold. The already prepared inferiorly-based vascularized dermal flap was then rotated and draped over the tissue expander into position to give lateral, medial and central coverage, and it was inset all the way around it with interrupted 2-0 Vicryl sutures between the edges of the inferiorly-based vascularized dermal flap and the pectoralis major muscle. The dermal flap covered most of the tissue expander. The wound was irrigated with half strength Betadine solution again and hemostasis was obtained with electrocautery. We placed two 15-French round JP drains in the subcutaneous pocket and brought them through separate stab incisions in the lateral aspect of the inframammary fold. Both drains were secured in place with a 3-0 Nylon suture. Then, we reapproximated the mastectomy skin flaps using interrupted 3-0 Monocryl sutures for the deep dermal layer, followed by a running 4-0 Monocryl suture in the subcuticular layer for the vertical limb and running 3-0 Monocryl Stratafix suture in the subcuticular layer for the horizontal limb.\\
+We then turned my attention to the left breast and a similar procedure was performed. We irrigated the breast pocket with half strength Betadine solution. An 17 x 11 cm inferiorly-based vascularized dermal flap was marked out based on the previously marked Wise pattern and this was deepithelialized. Hemostasis was achieved. The footprint of the breast and tissue expander were confirmed on the skin markings and on the pectoralis major muscle.  Based on the pocket's dimensions we selected a Sientra Dermaspan LPP-FH14S tissue expander with a 14 cm base diameter. The pocket was again irrigated with half strength Betadine and the skin was prepped with betadine.  Gloves were exchanged and the selected tissue expander was placed into the pocket. Prior to doing that the air was removed from the tissue expander, and it was filled with 250 cc of air. The tissue expander tabs were sutured to the chest wall with interrupted 2-0 Vicryl sutures, and we ensured that it was positioned along the lateral border of the breast and inferiorly along the inframammary fold. The already prepared inferiorly-based vascularized dermal flap was then rotated and draped over the tissue expander into position to give lateral, medial and central coverage, and it was inset all the way around it with interrupted 2-0 Vicryl sutures between the edges of the inferiorly-based vascularized dermal flap and the pectoralis major muscle. The dermal flap covered most of the tissue expander. The wound was irrigated with half strength Betadine solution again and hemostasis was obtained with electrocautery. We placed two 15-French round JP drains in the subcutaneous pocket and brought them through separate stab incisions in the lateral aspect of the inframammary fold. Both drains were secured in place with a 3-0 Nylon suture. Then, we reapproximated the mastectomy skin flaps using interrupted 3-0 Monocryl sutures for the deep dermal layer, followed by a running 4-0 Monocryl suture in the subcuticular layer for the vertical limb and running 3-0 Monocryl Stratafix suture in the subcuticular layer for the horizontal limb.\\
+The chest area and breasts were cleansed with normal saline. Mastisol and Steristrips were applied to the incisions. Biopatches and Tegaderms were placed on the drains sites.  She was placed into a surgical bra with fluffs.  The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. All counts were correct at the end of the case. I was present for the entire portion of my part of the procedure.\\
+Intraop Pics:\\
+{{:resident:img_7794.jpeg?400|}}\\
+{{:resident:img_7792.jpeg?400|}}\\
+{{:resident:img_7796.jpeg?400|}}\\
+</WRAP>
+</WRAP>
 ==== Clinic/Progress Notes and Discharge Instructions ====
 {{ :resident:kaoutzanis_notes_and_discharge_instructions.docx |}}