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--- resident:david_mathes [2019/09/19 21:14] – [Mathes Papers] melissa
+++ resident:david_mathes [2023/08/21 13:55] (current) – [Tissue Expander] ally
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-==== Mathes Papers ====
+===== Dr. Mathes Introduction =====
+Vanderbilt University, Nashville, TN - B.A., European History (High honors in History), Minor Degree in Studio Art, Magna Cum Laude (1988 – 1992)\\
+Tulane University Medical School, New Orleans, LA,  Doctor of Medicine (1992 – 1996)\\
+Categorical Surgical Resident - New York Presbyterian Hospital, Weill-Cornell Medical Center, Department of Surgery, New York, NY (1996 – 1998)\\
+Research Fellow - Massachusetts General Hospital, Harvard Medical School, Department of Surgery, Boston, MA (1998 – 2001)\\
+Categorical Surgical Resident - New York Presbyterian Hospital, Weill-Cornell Medical Center, Department of Surgery, New York, NY (2001 – 2003)\\
+Chief Resident and Clinical Instructor in General Surgery - New York Presbyterian Hospital, Weill-Cornell Medical Center, Department of Surgery, New York, NY (2003 – 2004)\\
+Resident in Plastic and Reconstructive Surgery - University of Texas, Southwestern Medical Center, Department of Plastic and Reconstructive Surgery, Dallas, TX (2004 – 2006)\\
+\\
+[[https://drive.google.com/open?id=1x5Ko-M9iv76_LexZ51ofW6HHqFhZ_l_0|Mathes Publications Link]]
-[[https://drive.google.com/open?id=1x5Ko-M9iv76_LexZ51ofW6HHqFhZ_l_0|Mathes Publications Link]]
+===== Operative Reports =====
+General Tips:\\
+[[medical_student:diep_post-op_protocol|Dr. Mathes' DIEP Post-Op Protocol]]\\
+Clip the artery or vein first on a flap? The artery first so the flap isn't engorged with blood\\
+Dr. Mathes preferred markings for breast cases? 9cm limbs always. prefers 6 cm NAC to IMF distance for final appearance.\\
+\\
+Thoughts on TE: Need to decide BW, height, volume and textured. Low height TE will preferentially expand the inferior pole, but have low volume. Sub-pect vs pre-pect. Always goes pre-pect except if the patient has had a previous breast augmentation in sub-pect position. Will still have an animation deformity.\\
+\\
+Pre-pect TE how do you place alloderm? Personal preference, two ways - drape vs wrap. 2 dead layers vs 3 layers. Draping uses less material. Wrapping constricts. Wrapping easier .\\
+Total submuscular drawback? Pain, pushes implant up (very constricting), slow expansion.\\
+\\
+Why not subcutaneous recon? Capsular contracture. But these studies were done in the 80s with radical mastectomies.\\
+\\
+If you are the only one doing something, you are likely the lone genius.\\
+\\
+The book is being written on how well all the pre-pect alloderm recon will hold up.\\
+\\
+Immediate vs delayed reconstruction? Smoking -- complication rate high. Can delay a few weeks. Some say if getting radiation and wants autologous, then can wait later. Can delay for very poor flaps. \\
+Previous irradiation? - Would not offer breast tissue expanders.\\
+If they have are GOING to have radiation? "Late" complication rate increases. Radiated skin does not expand as well. Most would expand completely, radiate and then perform implant exchange. Sloan Kettering paper - radiated after TE implant exchange. Most patients happy in that paper.\\
+Factor for delay for radiation - Obesity. UT SW paper - ostoperative complications delay the commencement of radiation therapy in patients who received neoadjuvant chemotherapy and undergo mastectomy with immediate breast reconstruction. The period from the last dose of neoadjuvant chemotherapy was equivalent between those that experienced postoperative complications and those that did not. Patients with a higher body mass index are more likely to experience postoperative complications, and this should be considered when offering tissue expanders to obese patients who have received neoadjuvant chemotherapy and require adjuvant radiation treatment.\\
+\\
+Direct to implant requirements - Good flaps, wants to be smaller.\\
+\\
+When using areola markers, he likes you to suture the vertical limb. TAKE OUT THE STAPLES OVERLYING THE NIPPLE POSITION. And REMARK the nipple with the skin loose. This is for all breast reductions/mastopexy etc. Hates the "Aycock" Areola markers. Uses 42 mm to cut and downsizes to 38 mm to inset the NAC.\\
+==== Free Gracilis Flap ====
+<WRAP group>
+<WRAP half column>
+Operative Report\\
+The patient was brought to the Operating Room, and was placed on the operating room table in the supine position.  The case began with Throacic by inserting a gastroscope and performing an esophagoscopy and the performing the exploration and removal of the hardware as dictated by their teams. Once they had completed their portion of their surgery we were called in to perform the gracilis free flap to the head and neck.\\
+ \\
+This surgery require two microsurgeon due to the re-operative nature of the surgery and the need for someone to expose the neck vessels while the flap was being harvested. \\
+ \\
+I began with the free gracilis flap harvest.  An incision which had been marked in preop with the patient was made with a 10 blade.   Dissection was carried to the fascia with electrocautery and the fascia was divided.   The gracilis was easily identified and dissected circumferentially.  The distal extent was identified using long retractors.  The SFA perforators were divided and controlled with medium clips or electrocautery.  The flap was then divided distally and dissected from distal to proximal.  The pedicle was identified and protected. The pedicle was then dissected under loop magnification to its origin. This required meticulous dissection under loupe magnification in order to obtain maximum length. \\
+ \\
+While I was harvested the free gracilis flap, Dr. Chong dissected out the facial vein and facial artery. As the patient had multiple head and neck surgeries in the past this increased the time and complexity of the dissection. He first made an incision and dissected down the vessels. He identified the marginal mandibular nerve and preserved it. He was then able to dissect free the facial artery and the facial vein. The artery was 2 mm and the vein was 2 mm. \\
+ \\
+Once the vessels were ready and had been transected and secured via atramtic clamps I harvested the gracilis free flap. The artery and 2 veins were clipped and transected. The flap was brought to the head and neck area and secured. The vessels were then prepared under the microscope. The vein was anastomosed using a 2.0 mm flow coupler and the artery was anastomosed with 9'0 nylon suture in an interrupted fashion. Good flow was noted and good signal from the venous coupler. We then worked to inset the flap. Dr, Weyant scrubbed into the case again and guided where he wanted the flap secured to close the dead space and to bolster the repair on the esophagus. This was done with several 3'0 Vicryl sutures, The rest of the flap was then closed to the sides of the incision with 3'0 Vicryl. Once the flap was in place and secured. We obtain 10 x 12 cm full thickness skin graft from the thigh donor site. This was obtained using a dermatome set at 12/1000th of an inch. The skin graft was punctured on the back table and then secured to the flap with 3'0 chromic suture. We also placed two 15 Fr drains which were secured by a 3'0 Nylon suture. The superior drain was under the flap and the more inferior one was in the deep space. A cutaneous doppler signal was identified and a 5'0 prolene was placed to mark the location.  \\
+\\
+The donor site was closed with a 15 blake drain in place using 3-0 monocryl deep dermals followed by a 4-0 monocryl subcuticular suture and covered with steri-strips. The skin graft donor site was covered and secured. \\
+ \\
+The patient was then transported to the CT ICU for monitoring of the flap and was noted to have good cutaneous doppler signal and good flow coupler sound.\\
+</WRAP>
+<WRAP half column>
+Tourniquet: finger / forearm / arm\\
+Drain: Yes/No\\
+Sutures: \\
+Dressing:\\
+Resident Notes:\\
+{{:resident:whatsapp_image_2020-05-14_at_6.02.50_pm.jpeg?400|}}
+{{:resident:whatsapp_image_2020-05-14_at_6.02.50_pm_1_.jpeg?400|}}
+{{:resident:whatsapp_image_2020-05-14_at_6.02.50_pm_2_.jpeg?400|}}
+</WRAP>
+</WRAP>
+==== Breast Reconstruction ====
+Skin closure 3-0, 4-0 monocryl. Does not "cross midline of the patient or breast" with closing sutures.\\
+For dressings he uses steri-strips and mastisol and he puts the mastisol right on the incisions.\\
@@ Line 12: / Line 93: @@
 Prep: Chloraprep
-===Tissue Expander to Implant Exchange===
-Intraoperative antibiotics. No antibiotics for home.
-Sutures: 3-0 vicryl for capsule, 3-0 monocryl deep dermal, 4-0 monocryl subcuticutlar
-===Fat Grafting===
-Intraoperative antibiotics. 1 week of Keflex for home.
-Close stab incisions with 5-0 fast gut. Steri strip dressing.
-==== Pimp Questions ====
+==== Breast Reduction ====
-Clip the artery or vein first on a flap? The artery first so the flap isn't engorged with blood
+<WRAP group>
+<WRAP half column>
+**Text in Column 1**
+Operative Report\\
+The patient was brought to the operating room, placed in supine position.  Bilateral sequential devices were placed, and patient was given intravenous antibiotics.  All pressure points padded.  A surgical timeout was performed.  We had marked her in the preoperative holding area with a Wise-type pattern breast reduction.  We used the larger 42 mm areola sizer and marked the areolas.  We then incised around the areolas with a 15 blade.  We then used a 10 blade to incise all of our lines of our Wise-type pattern.  We then deepithelialized the pedicle bilaterally.  We then raised our medial flap and our lateral flap bilaterally.  We then separated the pedicle from the superior flap, then removed the superior tissue, which was no longer necessary, removed the lateral tissue.  These were both sent for weights.  We then removed the medial and superior tissue until we got to a good volume.  We removed 505 grams from the left and 420 grams from the right.  We stapled, sat the patient up, and found they had good symmetry.  We irrigated.  We then closed with deep 3-0 Monocryl and running 4-0 Monocryl, Mastisol, and Steri-Strips.  We had marked nipple position, with the patient sitting up, using the 38 mm nipple sizer.  We then marked remove the staples in the area, re-marked it, and then deepithelialized it with a cruciate incision, brought out the nipple.  They were both pink and viable.  Closed with deep 3-0 Monocryl and running 4-0 Monocryl.  Mastisol and Steri-Strips were applied to this area.  Dressings were applied.  The patient was extubated and brought to the recovery room in stable condition.\\
+</WRAP>
+<WRAP half column>
+**Text in Column 2**
+Tourniquet: finger / forearm / arm\\
+Drain: Yes/No\\
+Sutures: \\
+Dressing:\\
+Resident Notes:\\
+Marking and Sizing the Nipple:
+Sit patient up once all incisions are stapled closed. Mark nipple position at area of greatest projection. Lie patient back flat and remove the staples within the marked nipple circle. With the same nipple sizer, make a new circle in the center of the prior marked circle. This smaller circle is now the new nipple position. De-epithelialize the skin within the circle and then cruciate the dermis. Pull nipple through and secure with interrupted 3-0 monocryl and then running 4-0 monocryl. **Mathes does not like 4-0 suture to cross T-junctions. Do individual running sutures for each limb.**\\
+{{:resident:whatsapp_image_2020-05-16_at_3.44.35_pm.jpeg?400|}}
+</WRAP>
+</WRAP>
+==== Umbilicus====
+Ties a 3-0 nylon suture the the internal medial and lateral walls of the umbilicus and leaves long tails (this is both to assist in incising and later orienting the umbilicus. Pull up on the 2 sutures and mark a small circle around the umbilicus for incision. Incise down to subQ tissue and stop. He likes to divide the inferior pannus in half and extend it up to the umbilicus incision then get around the stalk while holding the panniculus skin flaps in the other hand. When closing the abdomen pull the 2 sutures on the umbilicus out through the inferior incision. Before completely closing the incision, find the umbilical stalk and make a mark on the overlying skin. Cut out a 2x1cm circle and pull the sutures through, making sure orientation is good. Secure umbilicus with interrupted 3-0 monocryl and ½ buried 4-0 horizontal mattress sutures as needed. Dermabond.  (Mathes will also sometimes do an inferior flap incision for the new umbilicus location. It looks like an upside-down shield.)\\
+==== Tissue Expander ===
+Intraoperative antibiotics. Antibiotics for home\\
+Sutures: 3-0 PDS for TE and alloderm, 3-0 monocryl deep dermal, 4-0 monocryl subcuticutlar, Dermabond\\
+Pre-Pec- Duracell (16x20, cut to breast foot print) sew into IMF and circumferentially at Breast "SFS" don't really sew into muscle
+Horizontal mattress sutures to secure Duracell, make sure expander is as low as can go, the lower the better. Sew Duracell inferiorly first. Then place TE secure medially, then inferiorly (6 o'clock tab has bump). Then once TE's secured, sew Duracell superiorly/laterally. Place drain. Fill TE. Close with 3-0 and 4-0 Monocryl\\
+Placing the alloderm at the edge at the sternal edge of the pectoralis muscle may be a good option for Dr. Mathes' cases. Remember that the alloderm should be placed at the, at the IMF and the breast surgeon will violate the IMF on a regular basis. So you should be actually sewing the alloderm to the top of the flap, not to the chest wall. \\
+Places central tab at the breast meridian.\\ Only sews in 2 tabs for the TE.\\
+Hemostasis was first obtained. The base-width of the pocket was measured as 11 cm and a Mentor Artoura High Profile 300 cc tissue expander was chosen. A piece of alloderm was cut in the shape of the breast footprint and sutured into place with 3-0 PDS interrupted sutures. The tissue expander was then placed and the meridian, medial and lateral tabs sutured with 3-0 PDS interrupted sutures. A 15 french round drain was placed with the exit point in the lateral fold of the breast. Tissue expander was filled. The incision was closed with 3-0 monocryl deep dermal sutures followed by 4-0 monocryl running subcuticular sutures. The incision was dressed with Dermabond.
+==== Tissue Expander to Implant Exchange====
+Intraoperative antibiotics. No antibiotics for home.\\
+Sutures: 3-0 vicryl for capsule, 3-0 monocryl deep dermal, 4-0 monocryl subcuticutlar\\
+====Fat Grafting====
+Intraoperative antibiotics. 1 week of Keflex for home.\\
+Close stab incisions with 5-0 fast gut. Steri strip dressing.\\
 ==== DIEP ====
+MAKE SURE THE BED IS A REFLEX BED... not a chair bed.\\
 "Mark midline once patient is on table but BEFORE prepping
-If no CT scan, make sure you doppler out perforators BEFORE prepping"
+If no CT scan, make sure you doppler out perforators BEFORE prepping" - Make sure there is at least 1 perforator on each side of midline. No need to doppler out all of them.\\
+He spends a good amount of time measuring and making sure his abdominal marking elipse is even on each side. An old trick of his is to use the paper that the gloves come in to transfer the marks to the other side as a tracer.\\
 ==== Micro Take Back ====
@@ Line 33: / Line 164: @@
 Only remove A FEW staples if you think there is venous congestion. Hematoma should be handled in OR
+==== Right breast reconstruction revision with fat grafting, Left breast mastopexy, Abdominal scar revision ====
+DESCRIPTION OF PROCEDURE:
+The patient was brought to the operating room, placed in supine position.  Bilateral sequential compression devices were placed and patient was given intravenous antibiotics and pressure points were padded.  Surgical timeout was performed.
+We marked on the left side for a Wise-type breast reduction.  We first began by incising around the nipple using the 42 mm nipple sizer.  We then incised our incision markings, we then proceeded to elevate the medial and lateral skin and tissue flaps, deepithelialized the inferior central pedicle.  Once we had completed that, we then resected the lateral aspect of the tissue.   We then lifted up the superior flap, removed some tissue superiorly and laterally.  We then divided the inferior pedicle and noted good blood supply.  We then stapled into position after irrigating.  We then closed with deep 3-0 Monocryl and running 4-0 Monocryl. Sara Douglass was critical for retraction during the excision of the tissue and performed the majority of the suturing of the breast while I was able to work on the other side.  We then marked the nipple position with a 38 mm nipple sizer, surrounded it, deepithelialized it, a cruciate incision, brought the nipples, sewn in with deep 3-0 Monocryl and running 4-0 Monocryl.  It was pink and viable.  Mastisol and dressings were applied to that area.
+On the flap side, we elevated the flap superiorly about 8 cm, and resected approximately 1 cm of the mastectomy flap where it interfaced with the DIEP skin. There were some areas of firmness on the outside that when we elevated we found no evidence of fat necrosis on the flap. It appeared that this was scar in the chest wall. After we had elevated the mastectomy flap and excised the mastectomy skin we sat the patient up and noted that the lateral side was flat and that there was significant scarring. We then dissected laterally and opened up all the areas of scar in the area of the lateral chest. We placed a 15 french drain and secured it with a 3'0 Nylon. The flap was then stapled to the mastectomy flap.
+We then performed fat grafting to the upper pole and lateral area using 50 mL of fat, which we had processed by liposuctioning of the lateral flanks using the Revolve system.  We then excised an 8 cm area of her lateral scar. The scar was excised with subcutaneous tissue and fat.  We then lifted superior and inferior skin flaps and then closed with deep 3-0 Monocryl and running 4-0 Monocryl.  Mastisol and Steri-Strip dressings were applied.  The patient was then extubated and brought to recovery in stable condition.  I was present for all portions of this case. The flap was pink and viable at the end of the case as was the nipple on the reduction side.
+==== Removal of Tissue expander, Single perforator DIEP flap ====
+The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
+I was the co-surgeon for this free flap due to the complexity and difficulty in DIEP dissection, history of radiation, and need for advanced microsurgical expertise.  This operation qualifies for the S code due to the above reasons.
+The assistance of Sara Douglas, PAC was required as there was no senior plastic surgery resident available for the entire case.
+We utilized a two team approach. I exposed the mammary vessels.
+Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the alloderm. We then removed the intact tissue expander. Finally we removed the capsule. We then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV.  A laterally based sensory nerve was identified and preserved.  the connector and then the nerve alllograft was then sutured to the nerve with a 8-0 nylon suture.   Dissection was carried to the cephalad rib.  The artery was at least 3 mm and the vein was 3 mm.
+During this time we began the flap elevation portion of the operation by making the superior incision.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for 6cm. The flap dissection was then carried down to the rectus fascia.
+We then elevated the flap from lateral to medial starting on the left side . The lateral row had 2 perforators.  An oval incision was made around the umbilicus and carried down to the fascia. We then began the dissection on the from medial to lateral. There were 2 medial row perforators that were identified. These were all smaller on the left and we then dissected on the right where she had a large medial row perforator and smaller lateral row. We transected the lateral row and decided to base the flap off the medial row due to the size and quality. The remaining perforators were clamped with atraumatic clamps.  The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines.  The flap perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise. The flap perfused across the abdomen on the single perforator into zone 4 and the less perfused part was identified and marked and excised after a second spy run was performed with all of the other perforators ligated but the large medial row on the right side.
+We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  This added an additional 2 hours to each side.  The remaining perforators were then clipped and divided and the remainder of the dissection was then performed.
+We then brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a 3 mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin.  A sensory nerve on the flap was then anastomosed to the nerve allograft using the nerve connector and a 8-0 nylon suture.  The flap was then inset after we had de-epithelialized the portion of the buried flap. We excised some of the skin as it was damaged by radiation and made both superior and inferior darts to open the skin flaps. A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.
+The rectus fascia defect was then closed with buried 0 prolene in an interrupted figure of eight fashion. Two 15 blake drains were then placed. All drains were secured with 3-0 nylons and a biopatch. The skin was then closed with a 3-0 monocryl for the deep dermal layer. The skin was closed with 4-0 running subcuticular suture. The umbilicus was then incised on the abdominal wall the the umbilical stalk delivered. The umbilicus was then inset with 4-0 monocryl deep dermal sutures. The skin was then dressed with dermabond and the patient was placed into an abdominal binder.
+At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.
+==== Lympangiography ====
+The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
+At the time that I was called into the OR, the mastectomy had been completed.  The axilla was noted to be fibrotic.  I then injected the hand and upper arm with ICG and the SPY imaging device was brought into the field.  There was a trace of contrast uptake in the axilla.
+I then brought the operating microscope into the field.  The area that illuminated was dissected and several small lymphatic vessels were dissected.  They were noted to appear fibrosed and I then divided one - it did not have a functional lumen.  At this point, I decided that this reflected the status of her lymphatics and we stopped further dissection.  The lymphatic was clipped as a precaution.
+==== Bilateral tissue expander placement and bilateral serratus fascial flaps  ====
+The patient was brought to the OR and placed in the supine position.  Bilateral sequential compression devices were placed, the patient was given intravenous antibiotics, and pressure points were padded.  Surgical timeout was performed.
+Dr. Ahrendt did her bilateral skin-sparing mastectomies and axillary node dissection.  When she was complete, we then entered the operating room.  We first achieved hemostasis with electrocautery, and then lifted up a submuscular subpectoral flap all the way to her fold.  We were able to preserve tissue.  We then raised a lateral serratus fascial flap, incising the edge of the fascia near the lateral border of the pectoralis muscle, dissecting through, and including a small amount of the serratus muscle at the most inferior portion of the flap. We then took a 475 mL tissue expander, deflated it, placed it, and it was sewn in the lateral aspect with 3-0 PDS.  We then were able to close the pectoralis flap to the serratus fascia flap with 3-0 PDS.  We then placed a 15-French round Blake drain, which was sewn in with 3-0 nylon.  We then placed 120 mL sterilely into the tissue expander, and then closed the skin with deep 3-0 Monocryl and running 4-0 Monocryl.  We then did the same surgery on the right side, again lifting up the serratus fascial flap, dissecting it off at the insertion near the muscle interface with the pectoralis minor muscle, then preserving a thin fascial flap with a small amount of serratus muscle at the very distal portion.  We then lifted up our subpectoral flap, dissecting it all the way to the IMF.  We were able to preserve some subcutaneous fat and tissue in order to not need to use any human acellular dermal matrix.  We then irrigated, placed a 475 mL deflated tissue expander, and secured the lateral tab.  Then with a 3-0 PDS, closed the serratus fascia flap to the pectoralis muscle.  Irrigated.  They had already placed a drain in the axilla.  We placed another drain to drain the mastectomy flap area, sewn in with a 3-0 nylon as it was on the other side.  Irrigated.  Stapled closed.  We then did SPY angiography, which demonstrated excellent perfusion of both flaps.  Then, closed with deep 3-0 Monocryl and running 4-0 Monocryl.  Mastisol and Steri-Strips were applied.  Dressings were applied.  The patient tolerated the procedure and left the operating room in stable condition.  I was present for all portions of the case.
+==== Abodminal scar revision, diastasis correction, bilateral revision of reconstructed breasts, (fat graft)  ====
+After Dr. Arruda completed her case, we prepped and draped the abdomen and chest and thighs as per usual.  We made sure all pressure points had been previously padded.  She already had a Foley catheter placed.  We then proceeded to perform tumescence of her inner and outer thighs, and performed with tumescent of 1 liter of lactated Ringer, 1 ampule of epinephrine, and 20 mg of lidocaine.  We were able to get approximately 250 mL of fat into the Revolve system, which then allowed us to get approximately 110 mL of viable fat.  We then proceeded to layer this fat, make 2 stab incisions in the breast reconstruction, and allow this to layer the fat in the upper pole and lateral areas where she had some noticeable loss of contour.  We did 55 mL of fat per side.  Once this was complete, we closed the area with 5-0 fast and Dermabond.  The donor sites were closed with 5-0 fast.
+We then turned our attention to the abdominal incision, which was measured at 45 cm.  We excised 45 cm x approximately 5 cm at its maximum width to lower her scar and give her a better contour.  This area was then excised.  We then elevated her abdominal flap again up to the umbilicus, and then at the area over the left side of the DIP site.  We went all the way to the costal margin.  We then proceeded to imbricate and do a plication of her left fascia using interrupted 0 silks.  Once this was complete, we irrigated.  We then placed a 15-French round Blake drain, which was sewn in with 3-0 nylon.  We then stapled and closed with deep 3-0 Monocryl and running 4-0 Monocryl, Mastisol, and Steri-Strips for a length of 45 cm.  Dressings were applied.  The patient was then extubated and brought to the recovery room in stable condition.  I was present for all portions of our case.
+{{:resident:screen_shot_2021-01-02_at_2.53.31_pm.png?400|}}
+{{:resident:screen_shot_2021-01-02_at_2.53.37_pm.png?400|}}
+==== bilateral nipple reconstruction  ====
+We then turned our attention to the nipple reconstruction, which we had marked at 31 cm.  We then drew out a Tennessee-type flap, excised around the edges of the Tennessee flap, preserved the dermis and subdermal plexus as well as some flap fat in order to give it some projection.  We then folded these areas and closed the donor site with deep 3-0 Monocryl and running 4-0 Monocryl for the lateral portion.  The nipple reconstruction itself was constructed by sewing the ends together with 5-0 Monocryl.  Once this was completed and showed pink and viable nipple reconstruction, we then put Dermabond on that area.  We then applied Steri-Strips.  Dressings were applied.  The patient was then extubated and brought to the recovery room in stable condition.\\
+\\
+\\
+Resident Tips:\\
+Measure the base of the contralateral nipple and make that the base of the reconstructed nipple. Dr. Mathes' default is 12 mm. Some are smaller.\\
+\\
+As you raise the nipple, it looks like a "man trying to escape." Raise the wings first. Remember to try and keep some fat (from the flap) on them or the tips will die. Once you raise the flap, you want to raise the cap. DO NOT CUT THE BASE. When you are cutting the cap, think about keeping a nice chunk of fat on it so once it's cut, it will be "standing up" on that fat you raised. Before closing the nipple, close the wings. The first stitch you should take is near the base to close it. If you made the base too wide, you can always de-ep and then close. These should be deep dermals with 3-0 monocryl for the wings. The rest of the wing will now be almost an ellipse and you can close. Finish with a 4-0 running subq. Okay for a tail For the nipple, The parallelegram corners close top to top and bottom to bottom with simple interrupted 5-0 monocryl. Close the top and cap again with simple interrupted. He then dermabonds all of it and puts steri strips along the wings.\\
+==== Bialateral Tissue expander exchange to implants - bilateral circumaerolar mastopexy ====
+The patient was brought to the operating room, placed in supine position.  Bilateral sequential devices were placed, and patient was given intravenous antibiotics and pressure points were padded.  Surgical timeout was performed.  I first began by injecting 20 mL of 0.25% Marcaine with epinephrine into the drawn out lower abdominal incision.  We then made a 16 cm incision and then lifted up a skin flap superiorly, which measured approximately 6 cm in width.  We then tailor tacked this and cut off the excess skin, then closed with deep 3-0 Monocryl and running 4-0 Monocryl.  Mastisol and Steri-Strips were applied.
+We then turned our attention to the breast, first doing a periareolar mastopexy on both sides using the larger nipple sizer and then doing a 1 cm excision of skin circumareolar.  This was all deepithelialized.  SPY angiography for intraoperative assessment and perfusion was done and demonstrated good perfusion of the nipples bilaterally.  We then deepithelialized this area and then were able to close with deep 3-0 Monocryl and running 4-0 Monocryl, doing a periareolar mastopexy bilaterally.  Mastisol and Steri-Strips were applied.  We did do SPY angiography at several stages to demonstrate good perfusion, both when we did simple stapling and also when had deepithelialize and stapled.  Once this was complete, we then excised our old incisions for the placement of bilateral tissue expanders, removed the bilateral tissue expanders to the minor capsulotomy.  We then tried the 400 mL SSF Natrelle implants bilaterally, which gave good form and quality.  We then irrigated.  Hemostasis with electrocautery.  We then changed our gloves.  We used a Keller funnel and placed both implants with a no-touch technique.  We then closed the capsule with 3-0 Vicryl and deep 3-0 Monocryl and running 4-0 Monocryl.  Mastisol and Steri-Strips were applied.  Dressings were applied.  The patient tolerated the procedure and left the operating room in stable condition.  I was present for all portions of the case.
+==== Bialateral Breast Reduction ====
+The patient was brought to the operating room, placed in supine position.  Bilateral sequential devices were placed, and patient was given intravenous antibiotics.  All pressure points were padded.  Surgical timeout was performed.  We had marked her for a Wise-type pattern breast reduction.  We first began by using the larger areola sizer, 45 mm, marking the areolas, then incising around the areolas, then deepithelializing on each side central medial pedicle.  We then began our dissection, first making our medial flaps, then the lateral flaps, then removing a large amount of lateral tissue on each side and then dissecting our superior flap, trying to get them even approximately 1 to 2 cm.  Then removing the superior tissue bilaterally and then removing additional tissue until we removed approximately 472 grams on the left and 412 grams on the right.  We then irrigated, stapled closed, and noted that we had good symmetry.  We then closed with deep 3-0 Monocryl and running 4-0 Monocryl.  We then brought the nipples out using a 38 mm sizer, deepithelialized in a cruciate incision, brought it out and deep 3-0 Monocryl and running 4-0 Monocryl, Mastisol and Steri-Strips.  Dressings were applied.  We placed the 15-French round Blake drains, which were sewn in with 3-0 nylon.  The patient tolerated the procedure and left the operating room in stable condition.
+==== Brachioplasty ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Bilateral brachioplasty\\
+\\
+The patient was brought to the operating room, placed in supine position.  Bilateral sequential compression devices were placed, and patient was given intravenous antibiotics.  All pressure points were well padded.  The arms, chest, and abdomen were prepped and draped in normal sterile fashion.  She had been preoperatively marked for brachioplasty and panniculectomy.  We first did the brachioplasty.  We made our superior incision, dissecting a skin flap and subcutaneous tissue down to our lower marking, then transposing and then marking our lower extent of our excision excising that skin.  Hemostasis was achieved with electrocautery.  It was then closed with deep 3-0 Vicryl, running 4-0 Monocryl.  We placed a 10-French round Blake drain was sewn in with a 3-0 nylon.  Mastisol and Steri-Strips were applied and the arm was wrapped with Kerlix and Ace wrap.  That was 84 grams; 96 grams we were able to dissect out the right arm doing the exact same technique.  Making our superior incision, dissecting inferiorly transposing the marks and excising the inferior portion then closing with deep 3-0 Vicryl and running 4-0 Monocryl.  Mastisol and Steri-Strips were applied.  A 10-French drain had been placed before closure and sewn in with 3-0 nylon.  Dressings were the same.
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:screen_shot_2021-08-04_at_12.44.05_pm.png?600|}}
+Drain: 10 french round blake drain with 3-0 nylon suture\\
+Sutures: 3-0 vicryl deep dermal, 4-0 monocryl subcuticular\\
+Dressing: Mastisol Steristrips\\
+**Marking:** Mark bicpital groove. Mark out a line a couple cm above and see if it will pull down to groove. Pinch test and mark just shy of that. Can do same for inferior line. Doesn’t usually go into axillae \\
+Position: Arms out bilaterally. NO IVs in arms (put in legs). \\
+Procedure: Remark lines. Place several hash marks transversely. Make superior incision. Stay superficial. Make incisions along hash marks only as far as you know you can close. Staple this (true tailor tack). Can either excise the triangle you've created as you go or all at once after you've made and stapled each hash mark incision. Place a drain. usually smaller (7fr). Close with 3-0, 4-0, dermabond. Wrap with ACE. \\
+**Anatomy:** \\
+With the arm abducted and flexed at 90 degrees, the important landmarks for assessment are from the apex of the axillary crease to the olecranon\\
+The bicipital groove is the area between the biceps brachii above and the long head of the triceps below.\\
+In the bicipital groove, below the brachial fascia, lie several important neurovasculatur structures including the median and ulnar nerves and the axillary artery and vein.\\
+In the midportion of the upper arm over the bicipital groove, superficial to the brachial fascia, lies the medial brachial cutaneous nerve.\\
+In the distal portion of the upper arm over the bicipital groove, superficial to the brachial fascia, lies the medial antebrachial cutaneous nerve and the basilic vein.\\
+\\
+**Post-operative care:** \\
+Arm compression garment for 4 to 6 weeks.\\
+Keep arms elevated as much as possible.\\
+Do not exceed 90 degrees at the shoulder for 4 weeks.\\
+At 2 weeks, begin massage therapy +/- silicone.\\
+\\
+**Learning points/Pimp Questions:**\\
+Always perform excision in a segmental fashion. Failure to do so may lead to an incision that cannot be closed.\\
+If performing liposuction in combination with a brachioplasty, be sure to do liposuction and the excision immediately afterward on one arm at a time (unless a two-team approach). Otherwise, swelling can lead to decreased ability to excise the desired tissue or can lead to failure to close the arm.\\
+What is the most common complication? - Seroma\\
+What is the most commonly injured nerve? - Medial antebrachial cutaenous nerve.\\
+</WRAP>
+</WRAP>
+==== Thighplasty ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Bilateral Thighplasty\\
+\\
+The patient was brought to the operating room and placed in a supine position.  Bilateral sequential compression devices were not placed because we needed to prep her whole leg.  All pressure points were well-padded.  Surgical timeout was performed.  We had marked her in the preoperative holding area for a thighplasty incision, which included a bucket-handle extension.  We made our medial incision, then dissected laterally to our lateral marks, dissecting down, leaving a layer of fat over the muscle and fascia.  Multiple large vessels were encountered, which had to be divided with medium and large clips.  For hemostasis, we used electrocautery.  We then reached our dissection line.  We were then able to mobilize our medial skin laterally and then mark the excision marks along the entire thigh.  In her more inferior left thigh, she had a very large amount of skin.  We were able to debulk this and get a satisfactory closure once we had marked it, and we did tailor-tacking-type technique and then excised the skin and then stapled it closed.  We then unstapled, irrigated, and hemostasis achieved with electrocautery.  We placed a drain distally and proximally sutured with a 3-0 nylon.  We then closed with deep 3-0 Monocryl and running 4-0 Monocryl, Mastisol, and Steri-Strips.  This was done bilaterally.  We removed approximately 6.5 pounds of tissue, including the left and right thighs.  This was sent to pathology for final analysis.  Dressings were applied.  The patient was extubated and brought to recovery in stable condition.\\
+{{:resident:8e5a6a90-a7b9-4647-ad2a-e10cbf238e3b.jpeg?400|}}
+</WRAP>
+<WRAP half column>
+Photos\\
+{{:resident:screen_shot_2021-01-05_at_4.59.13_pm.png?400|}}
+Drain: 10 french round blake x2 for each side\\
+Sutures: deep 3-0 Monocryl and running 4-0 Monocryl\\
+Dressing: Mastisol, and Steri-Strips\\
+\\
+**MUST READ:** Mathes thighplasty paper with Kenkel [[https://pubmed.ncbi.nlm.nih.gov/18061810/]] \\
+**Marking:** Mark patient in standing position with legs at shoulder width. At this point can see if you need a transverse or vertical excision. Doesn't like to combine them as doesn't like the T-point incision. Pinch test to see what will close and be conservative. Doesn't necessarily follow the 4cm from vulva guideline-just places incision in the groin crease if transverse. \\
+**Position:** Frog leg. Uses 2 U drapes, one across belly and one across both legs. Can have SCDs below.\\
+Procedure: Remark lines. Place several hash marks transversely. Make superior incision. Stay superficial and above deep fascia, especially over sartorius. Can go deeper more lateral. Make incisions along hash marks only as far as you know you can close. Staple this (true tailor tack). Can either excise the triangle you've created as you go or all at once after you've made and stapled each hash mark incision. Place a drain. Close with 3-0, 4-0, dermabond. Wrap legs with ACE. \\
+**Anatomy:**\\
+Muscles in this should not be visualized as the muscular fascia is not penetrated; surgery only involves the skin and subcutaneous fat of the inner thigh.\\
+{{:resident:screen_shot_2021-08-04_at_12.55.33_pm.png?600|}}
+**Post-operative care:** \\
+Patients are followed on a weekly basis after surgery to assure optimal wound healing and drain care for the vertical approach.
+Drains can be removed when drainage is 30 cc or less for a few days.\\
+Compression of the leg from the toe to knee assists in preventing calf swelling.\\
+If suspicious swelling develops, particularly unilaterally, ultrasound should be performed to rule out deep venous thrombosis.\\
+Strenuous activity may be resumed 4 to 6 weeks after surgery as long as healing is uncomplicated.\\
+Longer-term care is provided for scar management, including topical therapies to reduce scar visibility and massage to assist in dysesthesias and edema.\\
+**Learning points/Pimp Questions:**\\
+If the patient has varicose veins, they should be treated first before the thigh lift.\\
+Thighplasty is rife with complications. At least small wound healing issues are almost inevitable.\\
+Other complications include:
+Lymphedema: Best minimized by avoiding any interruption of lymphatics or veins. Compression from toe to knee and elevation may help. If swelling is asymmetrical, workup for venous thrombosis should be considered.\\
+Labial spread: With any procedure that creates some tension with tissue removal and lack of proper suspension of tissues around the mons. Multiple interrupted sutures suspending tissue to periosteum helps reduce risk.\\
+Wound healing problems are more of an issue with higher weight patients; undermining and adjunctive liposuction should be minimized. Permanent large caliber sutures around the groin may become infected with wound healing\\
+problems, necessitating removal of the exposed suture.
+Unsatisfactory scar: symmetrical treatment with sequential, stepwise tissue excision and avoidance of high tension closure assists in optimizing scar. Irregular contour of the inner thigh with vertical thigh lift is not uncommon as posterior thigh tissue is thicker than the anterior tissues, so it is important to not pull posterior tissue forward.\\
+Venous thromboembolism: It is necessary preoperatively to check on any history or elevated risk as per the modified Caprini scale. Patients must be encouraged to ambulate after surgery.\\
+Infection is not common, and risk can be reduced by optimizing surgical conditions like addressing efficiency with reduced operative time and hypothermia, as well as initial dose of antibiotics prior to making incision. Seromas can become sources of infection and should be treated.\\
+</WRAP>
+</WRAP>