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--- resident:corrine_wong [2021/02/14 13:30] – [Operative Reports] jonathan
+++ resident:corrine_wong [2022/06/15 09:23] (current) – [Fibula Flap for Mandible Reconstruction] lindsay
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 Photos\\
+{{:resident:img_2704.jpg?400|}}
 Tourniquet: finger / forearm / arm\\
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 The patient was marked pre-operatively standing up. He was brought to the operative room and placed supine on the table. General anesthesia was administered and the patient was intubated atraumatically. SCD's were placed on bilateral lower extremities and pressure points were padded appropriately. Time out was performed, confirming patient's name, medical record number, date of birth, procedure and laterality. We infiltrated each breast with 150ml of wetting solution. This was comprised of 1L normal saline + 1mg epinephrine 1:1000. The patient's chest was prepped and draped in a sterile manner. We began by marking out the nipple areolar complexes (NAC) with the 25mm cookie cutter, and removed them with a knife as a full thickness skin graft. These were placed in a saline gauze and put on a back table. We worked on bilateral breasts simultaneously. We made the superior incision with a ten blade and Bovie, and ensured the mastectomy skin flaps were about 1.5cm, all the way down to the pectoralis fascia. We then made the inferior incision with a knife and Bovie, down to chest wall, and dissected the breast tissue off the pectoralis fascia. We then removed the breast tissue and passed them off for Pathology. We ensured hemostasis with Bovie cautery and stapled the incisions closed. We then sat the patient up and placed our NAC locations at about the 4th intercostal space, about 1.5cm superior to the incisions, and about 11cm from midline. After marking out the NAC locations, we sat the patient back down and de-epithelialized them. We removed the staples and checked the wounds again for hemostasis. We then washed out the wounds with normal saline. We placed a 15Fr drain in each wound and secured them with 3.0 Nylon. We closed the transverse incisions with  2.0 PDS in a 3 point suture, then with Vicryl 3.0, and lastly with 3.0 Covidien V-lock. These incisions were dressed with Steristrips and Dermabond. The NAC's were defatted and fenestrated with a 15 blade. These were secured on the chest with 5.0 Chromic. Bolsters made out of cotton balls, mineral oil and Xeroform were placed over the NAC grafts and tied over with 3.0 Silk. These were then covered with Tegaderms. The drains were dressed with Biopatches and Tegaderms. We then requested bilateral PECS blocks by Anesthesia, to assist in postoperative pain (please see their note for details). He was then placed in a compression vest and fluffs.
+**New** bolster instructions (as of 02/22/21):
+Adaptic buttered with Bacitracin ointment over the free nipple grafts, then telfa square, then 4x4 gauze folded into a small square for some compression, then Tegaderm. Steri-strips & Exofin, per usual, on the bottom incision.
 </WRAP>
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 Drains: 2x 15 french Blake drains, 1 on each side\\
-Dressing: Prineo, bolster, cover everything in telfa tegaderm, biopatch and tegaderm for the drain. Bolster is cotton balls, mineral oil and xeroform.\\
+Dressing: Prineo (or steri-strips and surgical glue), telfa bolster, cover everything in telfa tegaderm, biopatch and tegaderm for the drain. Bolster bacitracin, 3 layered telfa, tegaderm. **No longer using suture bolster**.\\
 Sutures: 2-0 PDS 3 point stitch. 3-0 nylon for drain. 3-0 silk for bolster. 3-0 vicryl for "SFS", 3-0 v-lock.\\
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 - Please call to confirm your follow up in 1 week\\
 - No NSAIDs for 2 days\\
+**For the Adaptic/bacitracin ointment/Telfa, no suture bolster:**
+**All dressings stay on until their next follow-up**.
+(Dr. Malliaris is still doing the Xeroform, cotton balls, mineral oil, sutured bolster & Tegaderm off after 48 hrs).
 </WRAP>
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 </WRAP>
+==== Thighplasty ====
+<WRAP group>
+<WRAP half column>
+DESCRIPTION OF THE PROCEDURE:  The patient was marked in the pre-operative area with a planned incision from the medial knee through the medial thigh and curving up laterally along the inguinal crease. The anterior portion of the incision was determined utilizing a medial vector pull test to determine the likely amount of tissue to be resected. The patient was brought back to the operative suite and remained on his stretcher in a supine position with an arm board table attached to the stretcher. All bony prominences were padded, SCD boots were placed. The patient was then identified and a proper timeout was taken, which all present parties were in agreement. General anesthesia was administered by anesthesia. The patient was then prepped and draped in the usual sterile fashion.
+We began by infiltrating the bilateral marked operative area with 180 mL of tumescence into each thigh (tumescence consisting of 1L of normal saline mixed with 1 mL of 1:1000 epinephrine). The anterior thigh incisions were then made using a #10 blade. Dissection was then carried straight down toward the muscular fascia and care was taken to not undermine anteriorly. Once at the level of the fascia, we began to undermine the flap posteriorly. Great care was taken to preserve the greater saphenous vein. Branches of the greater saphenous vein were clipped and transected sharply. Once undermining was deemed adequate and equal bilaterally, we began to determine the resection area of the posterior incision by tailor-tacking. The posterior incision was determined by placing a Cocher clamp on the dermis of the anterior flap then transposing the undermined posterior skin anteriorly and marking this point. This marked point was joined with the anterior incision and then this area was excised. Once cut this area was then stapled to ensure that the incision would close. The resected amount of tissue on the left was 0.6204 kg and on the right 0.6946 kg. The posterior incision was completed in this fashion and the entire marked area closed temporarily with staples to ensure that the wound was without undue tension.
+We then removed the staples and obtained hemostasis utilizing electrocautery. The wounds were then copiously irrigated with normal saline solution. 15 Fr round JP drains were placed both proximally and distally anterior to the the incision on the bilateral thigh. The drains were secured in place with a 3-0 nylon suture and biopatch with a Tegaderm dressing over the top. The incision was then restapled and the superficial fascial system closed with a running 2-0 V-Loc suture deep. The deep dermis and skin was then reapproximated with 3-0 VLoc in a running subcuticular fashion. Rescue stitches were placed with a 3-0 monocryl suture. The incisions were then covered with 1 inch steristrips and then exofin skin glue placed on top of this. The patient was then placed in compression leggings with abdominal pads over the incisions.
+All counts were correct at the conclusion of the case. Dr. Wong was present for the entirety of the case.  The patient was then subsequently extubated and brought to the PACU in stable condition and was admitted to the hospital for 23 hour observation.
+</WRAP>
+<WRAP half column>
+Photos:
+{{:resident:img_5650.jpg?400|}}
+Tourniquet: None
+Drains: 2x JP drains per leg - 1x at distal aspect of incision, 1x at superior aspect
+Sutures: 3-0 drains, 2-0 v-loc SFS, 3-0 Vloc subcuticular, 3-0 monocryl rescue stitches
+Dressing: 1 inch steri strips, Exofen glue, ABD pads, compression leggings
+Anatomy: Dissecting down to visualize and protect the Greater Saphenous vein; femoral triangle
+Post-operative care: Compression leggings at all times for 6 weeks, may shower after 48 hours (remove leggings and then replace)
+Learning points/Pimp Questions: Greater Saphenous vein, markings
+</WRAP>
+</WRAP>
+==== Fibula Flap for Mandible Reconstruction====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Free fibula flap for mandible reconstruction\\
+\\
+A tracheostomy, vessel dissection and preparation of the mandible was performed by Dr. Glasgow. Please see his operative note for the technical details of his portion of the case.\\
+\\
+The distal and proximal portions of the fibula were palpated and marked and the entirety of the fibular was drawn to length along the lateral aspect of the right leg. A doppler was used to identify perforators should a skin paddle be needed. 6cm was measured from both the distal and proximal aspect of the fibula for the planned osteotomy sites and as to ensure that adequate bone length remained at both ends. A scalpel was used to make an incision the length between the two osteotomy sites. Dissection was started on the distal aspect of the fibula near were the perforators were found. Dissection was carried down and through the muscle fascia and then laterally looking for perforators. Two perforators were found and preserved. While palpating the fibula through the muscles of the lateral compartment the dissection was taken down to the fibula both distally and proximally. Care was taken to leave a small 2mm cuff of muscle on the fibula to preserve the periosteum. Dissection was taken around the fibula in a medial direction , removing muscle off the fibula, until the anterior compartment was entered. We transected the anterior crural septum. Care was taken to not injury the anterior tibial artery and neurovascular bundle. At this point the decision was made to perform the distal and proximal osteotomies to aid in dissection and exposure. The proximal and distal aspect that had been previously marked for the osteotomy sites were exposed by dissecting the periosteum off the bone circumferentially. Care was taken to not injure the pedicle. A narrow malleable was placed on the back side of the bone over the pedicle to protect the vessels. A bone saw was used to create both distal and proximal osteotomies. This freed the fibula and allowed for better visualization. Dissection continued through the muscle to the interosseous membrane which was carefully incised with sharp dissection. A doppler was used to identify the pedicle and its location. Once this was confirmed dissection continued around the pedicle into the deep posterior compartment. At this point the distal aspect of the pedicle was identified and ligated to free up the distal aspect of the fibula with the pedicle attached on the medial side. Dissection was then continued from the inferior to superior direction around the fibula , removing the surrounding muscle from the flap. The doppler was used continuously to ensure the location of the pedicle. All perforating vessels were clipped and ligated. One of the perforators for the skin paddle was coming from the soleus muscle and one from the septum. The skin paddle was approximately 6 cm x 3 cm. The perforator from the soleus muscle was ligated and the paddle was freed from the underlying fascia. Once the proximal aspect of the fibular was reached the pedicle was followed from the fibula proximally into the leg. The bifurcation of the posterior tibial vessels was clearly seen and identified. The peroneal vessels were circumferentially dissected and ligated freeing the entire fibula along with its vascular pedicle. Hemostasis was achieved in the leg incision. The flexor halicus longus was sutured to the interosseous membrane with 3-0 vicryl sutures. The peroneus longus and soleus muscle were then sutured together to close the muscle using 3-0 vicryl sutures. A 15 french blake drain was placed through a separate stab incision on the inferior aspect of the leg and secured with a 3-0 nylon. The incision was closed with 3-0 monocryl deep dermal sutures followed by a 3-0 v-lok suture. The incision was dressed with exofin glue followed by an island dressing.\\
+\\
+The presurgical planning bone template was secured to the fibula at the most distal end and the osteotomy and screw hole sites confirmed and scored with a bovie. Working proximally on the fibula the periosteum and surrounding tissue was elevated off the bone with great care taken to not damage the pedicle. This was taken all the way down to the point of the proximal osteotomy. The middle osteotomy sites were similarly cleared of surrounding tissues. The lingual end of the fibua was lengthened as the condyle from the mandible was removed in order to provide additional bone. The harvested skin paddle would not fit in the reconstruction and was removed. Screw holes were pre drilled for the fixation and reconstructive bar screws. Fixation screws were placed to keep the template on the bone. A bone saw was used to make the osteotomies with care taken to avoid injury to the pedicle. The fixation screws were then removed and the bone segments aligned to the reconstruction bar. Screws were then placed and the fibula fixed to the reconstructive bar. The proximal aspect of the fibula that was to be placed in the cranial fossa for mandibular articulation was filed smooth and round by the OMFS team with a pineapple bur. The flap and reconstructive bar was inset and found to be in an adequate position. \\
+\\
+Following inset, the peroneal pedicle was dissected out and cleaned under a microscope. The left facial artery and branches of the external and internal jugular veins, which had been dissected out by the OMFS team were in good position relative to the pedicle vessels. Once the vessels were cleaned and aligned a vein sizer was placed under the scope and a 4.0 size flow coupler was used to complete the anastomosis using a Synovis flow coupler device. A hemostat was then used to ensure the two rings of the flow coupler were securely closed. The second vein was also anastomosed in the same fashion using a 3.0 flow coupler. Next our attention was turned to the arterial anastomosis. Adequate flow was noted from the facial artery which was clamped with a Biover clamp. After cleaning the vessel the anastomosis was performed in a back to front fashion with interrupted 8.0 nylon sutures. Next an implantable Cook arterial doppler was placed around the flap side of the anastomosis by wrapping the two ends around the artery and then using small clips to secure it in place. The incision was irrigated and hemostasis was achieved with electrocautery. A 15 F blake drain was placed through a stab incision on the inferior and lateral portion of the patients neck. The sub-maindibular incision was closed with interrupted 3-0 vycril sutures followed by staples. Elastic bands were placed to place the patient in MMF by the OMFS team. The incisions were dressed bacitracin.\\
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:ab7bdb58-aeb7-4cd5-8636-0b7f0444f964.jpeg?400|}}
+Tourniquet: Thigh (optional)\\
+Drain: 15 round french in neck and donor site\\
+Sutures: Donor - 3-0 vicryl for muscle, 3-0 monocryl deep dermal (few) and 3-0 v-lok. Neck 3-0 vicryl deep. Staples.\\
+Dressing: Surgical glue and island dressing for leg. Baci for neck\\
+Anatomy: \\
+Prefers Michael Zenn book free fibula chapter.\\
+Post-operative care:\\
+POD#0: ASA suppository (300 mg), NPO **per mouth** (okay for tube feeds), Unasyn q8 for 72 hours, peridex, light teeth brushing, no objects in mouth, drain care, ICU status with q1 hour flaps, wean vent, CAM boot for walking (6 weeks)\\
+POD#1: Q1 hour flap checks, ASA 81 daily, start lovenox daily\\
+Order PT/OT, SLP for speaking valve, RT to discuss downsizing trach/decannulation, nutrition for tube feeds\\
+POD#2-4: Space flap checks as appropriate\\
+POD#7: Check with OMFS to see if patient can be taken out of elastics. Dr. Wong is usually okay with discharge at 1 week. Donor site drain can be removed. Check with Dr. Wong regarding neck drain -- watching for spit.\\
+POD#14: Swallow test (MBSS) - if passes can have pureed diet.\\
+\\
+Discharge:\\
+Patient will leave with NG/PEG for tube feeds.\\
+Cut wires for flow coupler and cook doppler and tape with tegaderm. They will be pulled at clinic.\\
+ASA 81 for 1 month. No lovenox necessary.\\
+Attending Pearls (Learning points/Pimp Questions):\\
+Will ask about CPN\\
+Will ask about the compartment of the leg.\\
+- Try TPA if arterial anastomosis clots off
+- 5000U of heparin
+</WRAP>
+</WRAP>