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resident:justin_cohen [2019/10/19 15:23] – jonathanresident:justin_cohen [2020/08/16 19:26] (current) – [Operative Reports] jonathan
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-====Dr. Cohen Introduction====+=====Dr. Cohen Introduction=====
  
   * Princeton University, A.B. Department of Molecular Biology (2005)\\   * Princeton University, A.B. Department of Molecular Biology (2005)\\
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 [[https://drive.google.com/open?id=1mvipwqRX0aoAgOVh5G7lEGD1RXTlo_Fu|Dr. Cohen Publications]] [[https://drive.google.com/open?id=1mvipwqRX0aoAgOVh5G7lEGD1RXTlo_Fu|Dr. Cohen Publications]]
  
-==== Breast Reduction Procedure==== 
  
 +===== Operative Reports =====
 +
 +General Tips:\\
 +\\
 +
 +==== Breast Reduction (Superiomedial Pedicle) ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Superiomedial Bilateral Breast Reduction\\
 +\\
 +The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks as well as a wise pattern breast reduction using a standard template. The limbs were made slightly longer to accommodate the superiomedial pedicle.\\
 +\\
 +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 with chloroprep and draped in the standard fashion.\\
 +\\
 +A near identical procedure was performed on both breasts. All resected tissues were saved and sent to Pathology for routine histologic examination.\\ 
 +\\
 +A 42mm cookie cutter was used to mark a new ideal nipple areolar complex size.  A 9 cm superomedial pedicle was then de-epithelialized using 10 blade. The superomedial pedicle was then dissected away from the surrounding breast tissue down to the chest wall using electrocautery. The nipple was pink and viable during this process.  Skin flaps were elevated at full thickness as appropriate. I then removed the medial, inferior and then lateral breast tissue from the wise pattern outline. A small amount of back cut was utilized to allow the pedicle to rotate into the new nipple position. Once the resected specimen was removed the skin was tailor tacked with a stapler.\\
 +\\
 +I then turned my attention to the contralateral breast and an identical procedure was performed.  Upon completion of the contralateral resection, the patient was sat in an upright sitting position to assess for size, shape, and symmetry of the breasts.  All necessary adjustments were subsequently made to achieve excellent symmetry. The new nipple position was also selected at the most projecting part of the breast. Meticulous hemostasis and copious irrigation was then performed. 30cc of 0.5% Marcaine with 1:200,000 epinephrine was infiltrated in the pectoralis major muscle fascia for perioperative analgesia.\\
 +\\
 +The IMF, vertical limbs and periareolar incision were then closed with 3-0 monocryl into the dermis followed by a 4-0 running monocryl intracuticular. A 15F drain was placed into both breasts and secured with a 2-0 nylon at the lateral aspect of the incision. Dermabond was then applied all incisions.  Prineo was utilized for the triple point. The nipples were viable at the end of the procedure and the breasts soft.  She was placed into a surgical bra with ABDs. The patient tolerated this procedure without complication, and postoperatively she was extubated and brought to the recovery room in stable and satisfactory condition.
 +
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +
 +Tourniquet: finger / forearm / arm\\
 +Drain: Type of drain and placement\\
 +Sutures: List all layers\\
 +Dressing: What's preferred?\\
 +
 +Anatomy: Pertinent anatomy should be listed\\
 +
 +Post-operative care: Include restrictions, splints, etc...\\
 +
 +Learning points/Pimp Questions:\\
 +
 +**Position:** Supine, arms out and secured with 2 kerlix on each side, lower body bair hugger, SCD boots \\
 +**Prep:** Chloraprep if allergy will use betadine, careful not to rub off surgical site markings \\
 +**Draping:** Universal drape Will use: Skin stapler 4 blue towels Ioban strip cut into fourths \\
 +**Medications:** 30cc 0.5% marcaine with epinephrine Saline irrigation \\
 +Equipment: 2- ESU machines with smoke evacuators at foot of bed – Settings: 30/30 1-Bair hugger 1- Scale to weigh specimen \\
 +**Supplies:** 2 -Smoke evac bovie pencils 2- Teflon protected bovie tips 2- bovie grounding pads 4- 10 blades 4-marking pens 2- rulers 2-25g needles 2-10cc syringes 2-aspeto 1-Basin for irrigation 38, 42 and 45 cookie cutter Lap pads only no raytec sponges on field \\
 +*if specimen >900g will use 15F round drain with 2-0 nylon on PS-2 Sutures: 2-0 vicryl SH X 1 3-0 monocryl PS-2 x6 4-0 monocryl PS-2 X 6 3 skin staplers \\
 +**Dressing:** 4- Dermabond \\
 +* Have prineo available 6 ABD pads and bra Special Instructions: \\
 +* IF oncoplastic reduction WEIGH LUMPECTOMY SPECIMEN PRIOR TO SENDING \\
 +* At end of case please provide patient label and specimen weights on card for Dr. Cohen \\
 +
 +</WRAP>
 +</WRAP>
 +==== Breast Reduction (Inferior Pedicle) ====
 +
 +<WRAP group>
 +<WRAP half column>
 +
 +Operative Report:\\
 +1. Bilateral Breast Reduction Inferior Pedicle\\
 +\\
 +The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks as well as a wise pattern breast reduction using a standard template.\\
 +\\
 +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 with chloroprep and draped in the standard fashion.\\
 +\\
 +A near identical procedure was performed on both breasts. All resected tissues were saved and sent to Pathology for routine histologic examination.\\ 
 +\\
 +A 42mm cookie cutter was used to mark a new ideal nipple areolar complex size.  A 8 cm wide inferior pedicle was then de-epithelialized using 10 blade. The inferior pedicle was then dissected away from the surrounding breast tissue down to the chest wall using electrocautery. The nipple was pink and viable during this process.  Skin flaps were elevated at approximately 2 cm thickness. I then removed the medial, lateral and then superior breast tissue from the wise pattern outline.  There are some medial fullness left in order to maintain an aesthetically pleasing result.  Once the resected specimen was removed the skin was tailor tacked with a stapler.\\
 +\\
 +I then turned my attention to the contralateral breast.  Upon completion of the contralateral resection, the patient was sat in an upright sitting position to assess for size, shape, and symmetry of the breasts.  All necessary adjustments were subsequently made to achieve excellent symmetry.Meticulous hemostasis and copious irrigation was then performed. 0.5% Marcaine with 1:200,000 epinephrine was infiltrated in the pectoralis major muscle fascia for perioperative analgesia.\\
 +\\
 +The IMF, vertical limbs and periareolar incision were then closed with 3-0 monocryl into the dermis followed by a 4-0 running monocryl intracuticular.  Dermabond was then applied all incisions with Prineo to the IMF and T junction.  The nipples were viable at the end of the procedure and the breasts soft.  She was placed into a surgical bra with ABDs. The patient tolerated this procedure without complication, and postoperatively she was extubated and brought to the recovery room in stable and satisfactory condition.
 +
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Photos\\
 +
 +Tourniquet: finger / forearm / arm\\
 +Drain: Type of drain and placement\\
 +Sutures: List all layers\\
 +Dressing: What's preferred?\\
 +
 +Anatomy: Pertinent anatomy should be listed\\
 +
 +Post-operative care: Include restrictions, splints, etc...\\
 +
 +Learning points/Pimp Questions:\\
  
-**Dr. Cohen Gloves:** 7-blue latex free indicator / 7 - latex free\\  
-**Procedure:** Breast Reduction \\ 
 **Position:** Supine, arms out and secured with 2 kerlix on each side, lower body bair hugger, SCD boots \\ **Position:** Supine, arms out and secured with 2 kerlix on each side, lower body bair hugger, SCD boots \\
 **Prep:** Chloraprep if allergy will use betadine, careful not to rub off surgical site markings \\ **Prep:** Chloraprep if allergy will use betadine, careful not to rub off surgical site markings \\
Line 29: Line 120:
 *Have prineo available 6 ABD pads and bra Special Instructions: \\ *Have prineo available 6 ABD pads and bra Special Instructions: \\
 * IF oncoplastic reduction WEIGH LUMPECTOMY SPECIMEN PRIOR TO SENDING \\ * IF oncoplastic reduction WEIGH LUMPECTOMY SPECIMEN PRIOR TO SENDING \\
-**At end of case please provide patient label and specimen weights on card for Dr. Cohen \\+*At end of case please provide patient label and specimen weights on card for Dr. Cohen \\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Nipple Reconstruction ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Nipple Reconstruction\\ 
 +\\ 
 +The patient was brought into the operating room and placed in the supine position after intubation.  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.\\ 
 +\\ 
 +In the preoperative suite, I marked her nipple location at the meridian and X cm from her sternal notch.  This was also in the most projecting portion of the breast.  The sites were confirmed with the patient.  In the operating room C-V flaps with a base of 1.5cm and wings of 2.5 cm were designed - these were Superior vs Inferior  based incorporating her prior scar. The flaps were raised from distal to proximal, gradually increasing the flap thickness to the base.  There was healthy bleeding throughout.  The wings were then wrapped around the base and sutured together with 4-0 chromics.  The cap was sutured down with a 4-0 chromic.  The donor site was closed with 3-0 and then 4-0 monocryl.\\ 
 +\\ 
 +I then applied bacitracin and placed a protective sponge cap around the nipple.  This was held in place with tape.\\ 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Augmentation/Mastopexy ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Bilateral revision mastopexy/augmentation with complete capsulectomy during implant removal\\ 
 +\\ 
 +The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks as well as a wise pattern breast reduction using a standard template. The limbs were made slightly longer to accommodate the shape of new implants.\\ 
 +\\ 
 +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 with chloroprep and draped in the standard fashion.\\ 
 +\\ 
 +A near identical procedure was performed on both breasts.\\ 
 +\\ 
 +We began using the lateral limb of the Wise pattern incision bilaterally to access the submuscular current implant pocket.  The capsule was kept intact for the entire procedure whereby we dissected it free from the current pocket in all positions. This was performed with electrocautery and lighted retractor. The entire capsule was then removed and sent to pathology bilaterally. The implants were X implants bilaterally. The left was noted to be intact whereas the right was ruptured. Following removal of the implants the breasts were washed out thoroughly with saline. We then placed a SS sizer into the pocket. The breast was tailor tacked to approximate a wise pattern mastopexy.\\ 
 +\\ 
 +A 42mm cookie cutter was used to mark a new ideal nipple areolar complex size since it was too large.  The skin was then resected in a wise pattern with careful attention to symmetry. The nipple was pink and viable during this process.  The patient was sat in an upright sitting position to assess for size, shape, and symmetry of the breasts.  All necessary adjustments were subsequently made to achieve excellent symmetry.\\ 
 +\\ 
 +We elected to choose a SS which was placed into the previous submuscular augmentation pocket as this had the proper dimensions as well as produced the nicest aesthetic result. The pocket was washed out thoroughly and rinsed with betadine. The parenchymal opening was closed with 2-0 vicryl.\\ 
 +\\ 
 +The IMF, vertical limbs and periareolar incision were then closed with 3-0 monocryl into the dermis followed by a 4-0 running monocryl intracuticular. Prineo was utilized IMF incisions and dermabond for the rest. The nipples were viable at the end of the procedure and the breasts soft.  She was placed into a surgical bra with ABDs. The patient tolerated this procedure without complication, and postoperatively she was extubated and brought to the recovery room in stable and satisfactory condition.\\ 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Latissiumus Flap ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1.  Latissimus dorsi pedicled flap,  split thickness skin graft, wound vacuum placement\\ 
 +\\ 
 +The patient was marked in the preoperative area for anatomic landmarks of the latissimus including axillary line lateral border of the muscle posterior superior iliac spine and posterior midline as well as the scapular tip.\\ 
 +\\ 
 +The patient was brought into the operating room and placed in the lateral decubitus 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 sterile fashion.\\ 
 +\\ 
 +An incision was made from the axilla to the back along the axis of the latissimus muscle using a 10 blade scalpel.  Electrocautery was used to elevate skin flaps anteriorly and posteriorly and to clearly identified the latissimus muscle.  The anterior border of the latissimus muscle was identified and was dissected free from the serratus. The latissimus was then circumferentially dissected initially anteriorly then inferiorly and posteriorly.  Once these 3 borders were freed.  The muscle was elevated from distal to proximal.  All large perforators were clipped with medium ligaclips. The pedicle was identified at its entry into the muscle along with the serratus vascular pedicle.  The pedicle was dissected to allow adequate rotation into the wound with minimal tension. The donor site was then irrigated with normal saline and then closed over two 15 blake drains and secured to the skin with 2-0 nylon. The wound was closed with 2-0 Vicryl into the Scarpa's layer, 2-0 V-loc PDO suture for the deep dermal layer followed by a 3-0 monocryl suture for the subcuticular layer.  The donor site was then dressed with Dermabond and an OpSite dressing.\\ 
 +\\ 
 +Attention was then paid to flap inset.  The latissimus flap was spread out to cover the entire wound and provide sufficient dead space fill.  It was then secured into position using a 2-0 Vicryl suture in a parachuting fashion horizontal mattress through the skin.  This was performed at multiple points along the entire periphery of the flap.  A 15 French Blake drain was placed underneath the flap and secured to the skin with a 2-0 nylon.\\ 
 +\\ 
 +The wound measured approximately X cm x Xcm. A template was created and then transferred to the thigh and a dermatome set at 12 one thousandth of an inch thickness was used to obtain a STSG.  The skin graft was then meshed at 1:1.5.  It was placed on the wound bed and secured with 4-0 chromic suture. A VAC dressing was then applied over adaptec and the graft then placed at 125mmHg continuous. Minimal leak was noted. Of note this VAC was a inpatient version which is durable medical equipment and not disposable and will remain in position for 5 days while the patient is admitted to the hospital. The lower leg was then wrapped with a loose kerlix and ACE warp. The donor site was managed with mepliex dressing and then wrapped with a large ACE.\\ 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Wound vac; 15 round blake drains (2 to latissimus donor site and 1 to wound)\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Gynecomastia ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Gynecomastia correction with VASER liposuction\\ 
 +\\ 
 +The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks, topography, and breast footprint.\\ 
 +\\ 
 +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 with chloroprep and draped in the standard fashion.\\ 
 +\\ 
 +A near identical procedure was performed on both sides of the chest.\\  
 +\\ 
 +An 11 blade scalpel was used to make 2 nicks in the skin for access for tumescent. One was in the superolateral and the other in the inferolateral. Each breast was then tumesced using standard tumescent solution and cannula. X cc was placed into each side. Adequate time for hemostasis was allowed. Next skin protectors were placed on the skin and secured with staples. X minutes of VASER energy was added to each side of the chest at 80% power. I alternated between using a 2-ring and 5-ring device to assist with breaking up fibrous tissue and disrupting the fat and breast tissue. Next a 3 mm liposuction cannula was used to thoroughly and symmetrically remove all the excess fat and breast tissue. Cross hatching through the access incisions was performed. Special attention was paid to the retro areolar tissue. Contour irregularities were smoothed out and multiple pinch thickness tests were performed. The patient was also sat up multiple times during the procedure to assess for symmetry and optimal aesthetic outcome. There was a very smooth contoured symmetric male chest at the end of the procedure. Approximately X cc were removed from each side.\\ 
 +\\ 
 +The wounds were then closed with interrupted 5-0 fast gut sutures, along with steristrips, and OPsites. He was placed into an abdominal binder on the chest with ABDs. The patient tolerated this procedure without complication, and postoperatively he was extubated and brought to the recovery room in stable and satisfactory condition.\\ 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Gracilis Flap ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Perineal reconstruction with gracilis flap\\ 
 +2. SPY indocyanine green fluorescence angiography\\ 
 +\\ 
 +The patient was brought into the operating room and placed in the lithotomy 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 began with the gracilis flap harvest.  A curvilinear 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.  A tunnel was dissected through the soft tissue to the defect and the flap was passed into the perineum atraumatically.  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.  Dermabond was applied and the leg wrapped with an ace bandage. 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\Post-operative care: Include restrictions, splints, etc...\\Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== V-Y Gluteal Fasciocutaneous Flaps ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Washout and debridement of sacral wound, size 9.5 x 6.5 cm, with removal of skin, subcutaneous tissue, muscle, and bone, which was nonviable, bilateral V-Y gluteal fasciocutaneous advancement flaps, size 9.5 x 13.5 cm each, incisional wound VAC placement, 9.5 x 2 cm.\\ 
 +\\ 
 +The patient was brought to the operating room, and general anesthesia was induced per protocol.  She was placed prone on the table, and all pressure points were padded.  The wound was subsequently prepped and draped in the standard sterile fashion using Betadine.  A preoperative timeout was performed to verify the procedure and the patient.  The previous nylon sutures in position were removed.  The wound was inspected, and it was determined to be a 9.5 x 6.5 cm wound of the sacrum with involvement of the skin and subcutaneous tissue, as well as muscle and bone.  All nonviable tissue was debrided sharply, either with scissors or curets.  Healthy bleeding tissue was established at all levels with the bone having punctate bleeding, as well as the skin and subcutaneous tissue.  A rongeur was also used to debride the bone pieces that were considered to be sharp and potential niduses for pressure points.  There did not appear to be any active infection; however, there was some poor vascularized tissue, which was nonviable, and subsequently debrided.  The thecal sac of the dura was noted within the wound, and its integrity was maintained throughout the entire case.  After all nonviable tissue was removed, pulse lavage with 3 liters of normal saline was performed to irrigate out the previous antibiotic beads, as well as to wash away any extraneous tissue and provide as clean a wound as possible.  The wound was examined at this time and deemed appropriate for flap closure.  All previously radiated skin was removed at this time, and we felt it would be advantageous to attempt reconstruction.\\  
 +\\ 
 +Two large bilateral V-Y advancement gluteal fasciocutaneous flaps were designed.  The total length of these flaps was 9.5 x 13 cm on each side.  A 10 blade scalpel was used to create an incision.  This was further deepened with electrocautery down to the gluteal muscle over the entire length of the flap.  The fascia was incised in order to enable better rotation.  Meticulous hemostasis was obtained over the entire area.  The flaps were then tested on their mobilization.  They did not yet mobilize adequately, and therefore, areas of thick scar tissue were checkerboarded in order to allow for better advancement of the flaps bilaterally.  There was noted to be punctate bleeding at the edge of the flap from the dermis and, therefore, even after extensive undermining, as well as scoring, the flaps themselves had excellent blood flow and good capillary refill.  The bilateral advancement flaps were subsequently moved to the midline to cover the sacral wound, as well as the exposed bone and thecal sac.  This was initially tailor-tacked into position in a V-Y fashion.  The area of repair was subsequently closed with a 2-0 PDS suture into the Scarpa fascia and to provide a deeper layer of closure.  This also included closure of 2-0 PDS of the deep dermis.  The superficial dermis and epidermis were closed in interrupted fashion using 2-0 nylon suture.  It should be noted that a 10-French round drain was placed underneath the flaps prior to their being set into position under minimal tension.  The donor sites for these flaps were subsequently closed with a 2-0 Vicryl suture into the Scarpa fascia, as well as the dermis, and subsequently an intracuticular 3-0 Monocryl suture was used to reapproximate the skin.  Once the flaps were mobilized into position, they were on minimal tension.  There was excellent blood flow and capillary refill, as well as good expected viability of the flaps.  The drain was put to suction and secured to the skin with a 2-0 nylon suture.  Based upon the high concern for breakdown of this wound, an incisional VAC was placed over the central area of the flaps coming together in the midline.  It should be noted that perforators to the fasciocutaneous flap were not directly visualized; however, as many as possible were preserved in order to maintain this blood flow.  The incisional VAC was placed on the wound and had good suction.  The donor site to the flaps was dressed with Dermabond, as well as OpSite dressings.\\   
 +\\ 
 +The patient tolerated the procedure well without complication.  She was subsequently brought to the PACU in stable condition after extubation.  The size of the wound VAC was 9.5 x 2 cm.  The plan for that VAC is for it to remain in position for 7 days.  Strict postoperative instructions were provided to the team with regards to positioning and pressure offloading. 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Gastrocnemius Flap ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Medial gastrocnemius flap;  wound preparation of recipient site approximately X sq cm;  split thickness skin graft X sq cm\\ 
 +\\ 
 +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.  A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision. The patient is already on antibiotics and therefore up-to-date on dosing.\\ 
 +\\ 
 +We found a left pretibial wound, which was deep and tunneled to bone with stripped periosteum. Based upon the nature of this wound, the large amount of dead space and exposed bone it was deemed appropriate for flap coverage. A medial gastrocnemius flap was prepared.\\ 
 +\\ 
 +The incision was made approximately 2 cm posterior to the most medial aspect of the tibia curving towards the popliteal fossa. After the incision was made sharply with the scalpel, electrocautery was used to elevate the skin overlying the muscle being sure to protect the saphenous vein. No branches of the vein were encountered and was therefore safely preserved. We quickly came down upon the medial gastrocnemius, which was easily identified. We then elevated the skin flaps both anteriorly and posteriorly. The skin flaps were elevated posteriorly until we found the midline raphe between the medial and lateral gastroc. We were sure to preserve the lesser saphenous vein as well as the sural nerve, which was encountered in its proper position along with the plantaris tendon. Once the muscle was completely freed up on the anterior and posterior using a combination of sharp and blunt dissection, the gastrocnemius was determined to be completely mobile. We then measured to ensure that the flap was of adequate length given its arc of rotation such that it would fill the wound easily and not be placed on any tension. Following this, the gastroc muscle was divided at its most distal aspect near the Achilles tendon being sure to preserve the soleal and lateral gastroc aspect of the Achilles tendon. The muscle was then divided distally and bleeding was confirmed at its most tendinous and distal edge. Following this, the muscle was elevated in a distal to proximal fashion being sure to elevate just the gastroc and leave the soleus down in position. Once the flap was elevated all the way up to its pedicle, it was determined that muscle was still viable and pink. The pedicle was not directly visualized. However, it was palpated in the popliteal fossa. The underlying fascia of the gastroc was then scored using electrocautery to provide better excursion and lay into the area of the wound.\\ 
 +\\ 
 +With the flap completely elevated and viable, our attention was then turned to the recipient site. The edge of skin surrounding the wound was indurated and scarred and therefore it was freshened up at this time. Therefore, the total size ofthe wound at conclusion of the debridement to fresh healthy tissue. A tunnel was created in the subcutaneous plane to allow passage of the very bulky muscle without any tension into the area of the wound. This was done with also a combination of sharp and blunt dissection. The flap was then passed with Allis clamps into the area of the wound. It fit well without undue tension. Following this, the flap was sutured into position in a parachute fashion using a 2-0 PDS suture. This helped to hold the edge of the flap using the tendon to completely cover the wound. This was performed in an interrupted fashion. Once the flap was properly sutured into position, the donor site from the medial gastroc region was irrigated copiously with saline. A 15 JP drain was placed and secured with a 2-0 nylon. The wound was closed with 3-0 Monocryl suture into the dermis and 4-0 Monocryl running suture was placed into the cutaneous portion of the incision. The incision was then covered with Dermabond.\\ 
 +\\ 
 +With a flap sutured down in position, a 14:1000 inch skin graft was taken from the superiorposterior thigh using a dermatome. Approximate size of this skin graft was X cm x X cm. The skin graft was then meshed 1.5:1 and placed over the gastroc flap overlying the wounds. It was sutured inposition with a running 4-0 chromic suture. It was then bolstered in place using Adaptic and a wound VAC sponge with suction. The suction was placed to 125mmHg, continued with medium suction. The muscle was clearly viable at the completion of the operation.The skin graft donor site was dressed with a MepilexAg, Kerlix and ACE wrap. The wound VAC was used to dress the area of the knee wound and the donor site forthe flap was dressed with an OpSite dressing. The patient was subsequently placed into a knee immobilizer to keep him from bending his knee and pulling on his repair.\\ 
 +\\ 
 +At the conclusion of the procedure, the patient tolerated it well and without complication. He subsequently was transferred back to the bed after he was extubated and awakened. He was then brought to the postoperative care unit for continued recovery and eventual return to his hospital floor room. He will remain on antibiotics per Infectious Disease and Orthopedic Service. He is to have that VAC in place for approximately 5 days time, at which point it will be removed and the drain that is placed to remain for minimum 1 week. 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Breast Revision (Fat Grafting) ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Revision breast reconstruction-fat grafting\\ 
 +\\ 
 +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.\\ 
 +\\ 
 +We then focused on the bilateral breasts and their areas of tethering and asymmetry. The bilateral breasts had the old scar excised based on very thin poor quality skin and widened appearance. Total length of scar revision to chest 15cm.\\ 
 +\\ 
 +Dissection was carried slightly above the incision to enter the capsule. On the right there was a X cc MV intact tissue expander. On the left was the same.  A lighted retractor was used along with electrocautery to perform a capsulotomy and capsulectomy bilaterally. The pocket was opened to create a symmetric and round pocket bilaterally. The right pocket was lowered significantly at the IMF to provide better symmetry. This involving incising the capsule an dissecting precisely to created a nice IMF fold. This was was secured with 2-0 PDS in an interrupted fashion to try to re-approximate the IMF.  Multiple sizers were used to determine the ideal shape and position.\\ 
 +\\ 
 +Hemostasis was confirmed. Both pockets were then irrigated copiously with saline and the skin was also cleansed. Gloves were changed and new instruments were used. SS X cc implants were place bilaterally into the pockets with care to avoid contamination. The incisions were then tailor tacked closed and the patient sat up multiple times to confirm symmetry. The left breast had some excess skin and ptosis and therefore this was trimmed utilizing the current transvere incision. Once we were satisfied with the appearance, the capsule was closed with 2-0 vicryl interrupted. The dermis was closed with 3-0 monocryl and a 4-0 monocryl for intracuticular sutures.\\ 
 +\\ 
 +Dermabond was applied to the breast incisions. She was placed into a surgical bra with fluffs. She tolerated the procedure without difficulty and was extubated and transferred to recovery in stable condition.  
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Breast Revision (Capsulectomy/Exchange) ==== 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Revision breast reconstruction major with capsulectomy and capsulotomy bilaterally, removal of bilateral tissue expander, placement of bilateral silicone breast implants for reconstruction, scar revision to breasts 15cm total length\\ 
 +\\ 
 +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.\\ 
 +\\ 
 +We then focused on the bilateral breasts and their areas of tethering and asymmetry. The bilateral breasts had the old scar excised based on very thin poor quality skin and widened appearance. Total length of scar revision to chest 15cm.\\ 
 +\\ 
 +Dissection was carried slightly above the incision to enter the capsule. On the right there was a X cc MV intact tissue expander. On the left was the same.  A lighted retractor was used along with electrocautery to perform a capsulotomy and capsulectomy bilaterally. The pocket was opened to create a symmetric and round pocket bilaterally. The right pocket was lowered significantly at the IMF to provide better symmetry. This involving incising the capsule an dissecting precisely to created a nice IMF fold. This was was secured with 2-0 PDS in an interrupted fashion to try to re-approximate the IMF.  Multiple sizers were used to determine the ideal shape and position.\\ 
 +\\ 
 +Hemostasis was confirmed. Both pockets were then irrigated copiously with saline and the skin was also cleansed. Gloves were changed and new instruments were used. SS X cc implants were place bilaterally into the pockets with care to avoid contamination. The incisions were then tailor tacked closed and the patient sat up multiple times to confirm symmetry. The left breast had some excess skin and ptosis and therefore this was trimmed utilizing the current transvere incision. Once we were satisfied with the appearance, the capsule was closed with 2-0 vicryl interrupted. The dermis was closed with 3-0 monocryl and a 4-0 monocryl for intracuticular sutures.\\ 
 +\\ 
 +Dermabond was applied to the breast incisions. She was placed into a surgical bra with fluffs. She tolerated the procedure without difficulty and was extubated and transferred to recovery in stable condition.\\ 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Split Earlobe Repair ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Repair of split earlobe\\ 
 +\\ 
 +With the patient sitting, the margins of the clefts were marked. The area was then infiltrated with 2 cc of 1% lidocaine with epinephrine and 0.5% bupivicaine. Adequate time was allowed for hemostasis and anesthesia.\\ 
 +\\ 
 +The patient was placed in supine position on the bed.  The procedure was performed on the right side. The margins of the cleft were incised sharply with an 11 blade scalpel to create a V-shaped excision pattern. The inferior margin was carefully cut to make sure it would allow for proper approximation.\\ 
 +\\ 
 +The wound was completely closed with a 5-0 chromic suture in an interrupted fashion. The first suture being placed at the inferior margin to ensure no notching. The anterior surface of the ear lobule was done first followed by the posterior surface. At the conclusion of the procedure all edges are well approximated and there was a nice smooth curvature to the helix. Following this the patient was again cleansed and Steri-Strips were applied.\\ 
 +\\ 
 +The patient tolerated the procedure well and without complication she was given followup instructions and I will see her in one week time.\\ 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Direct to Implant Breast Recon ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Breast reconstruction with direct to implant reconstruction and acellular dermal matrix. Intraoperative SPY angiography to assess perfusion.\\ 
 +\\ 
 +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.  A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision. Please refer to the breast surgeon's op note for full details of the mastectomy. Mastectomy Weight: X g\\ 
 +\\ 
 +At the time that I was called into the OR, the mastecomy had been completed.  I began with the first side - the mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery.  Spy angiography was utilized to assess the perfusion to the mastectomy flaps.  All areas of the mastectomy flap appeared viable except for a small portion at the superior aspect which had a relative perfusion of less than 30%.  These were debrided with 15 blade and electrocautery.  I then irrigated the pocket with saline.  A sheet of 16 X 20  cm size AlloDerm which was perforated by myself had been prepared as per manufacturers guidelines was then placed into the wound.  It was initially sized to the wound using a # sizer.  Once the excess AlloDerm was trimmed it was placed into the wound and sutured into position in the medial superior and lateral aspect using interrupted 2-0 Vicryl sutures.  The same sizer was then placed into the wound and it was closed temporarily.  The patient was set up multiple times to assess for symmetry and implant position.  Once were happy with the appearance and excellent symmetry we then performed another spy angiography run to assess for blood perfusion.  All areas were greater than 30% relative perfusion at this time with the implant in position.  I then removed the sizer irrigated the pocket again with saline and we prepped the skin with betadine.  Gloves were exchanged and an implant was placed into the pocket.  The inferior aspect of the incision was then closed with interrupted 2-0 Vicryl sutures suturing it to the chest wall.\\  
 +\\ 
 +Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline.  Two 15 blake drains were placed and sutured with a 2-0 nylon. The entire edge of skin was subsequently de-epithelialized.  The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl intracuticular.\\ 
 +\\ 
 +The wounds were cleansed and dressed with Biopatches for the drains and dermabond applied to the incisions.  She was placed into a surgical bra with fluffs.  She was extubated and transferred to recovery in stable condition.   
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: 2 X 15F Blake drain\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\Post-operative care: Include restrictions, splints, etc...\\Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Deep Inferior Epigastric Artery Perforator Free Flap (DIEP) ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1.  Breast reconstruction with DIEP flaps -  S code\\ 
 +(22 modifier if S code not applicable, muscle preservation and length of dissection)\\ 
 +2.  SPY fluorescence imaging of skin perfusion based on perforator dissection\\ 
 +3. Debridement of mastectomy flap skin total length X cm\\ 
 +\\ 
 +The patient was marked preoperatively in the holding area for anatomic landmarks, as well as the above-mentioned surgery. 5000 units of heparin was given subcutaneously in the preoperative area.\\ 
 +\\ 
 +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. Foley catheter was placed.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.\\ 
 +\\ 
 +The co-surgeon for this free flap due to the complexity and difficulty in DIEP dissection, and the need for advanced microsurgical expertise.  This operation qualifies for the S code due to the above reasons.\\  
 +\\ 
 +We utilized a two team approach. Dr. X exposed the mammary vessels.\\  
 +\\ 
 +Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the pectoralis - bilaterally.  We then identified the 4th 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.  Dissection was carried to the cephalad rib.  The artery was approximately ? mm and the vein was ? mm.   
 + 
 +We then dissected out the vessels on the contralateral side and the exact same approach was utilized. The artery was at least ? mm and the vein was ? mm.   
 + 
 +During this time we began the flap elevation portion of the operation. A circumferential incision was created with a 15 blade around the umbilicus. The umbilical stalk was freed from the surrounding soft tissue using electrocautery. The superior incision was then made.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made the lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for ? cm. The flap dissection was then carried down to the rectus fascia.  
 + 
 +We then elevated the flap from lateral to medial starting on the first side . The lateral row had X# perforators and we then made the midline incision. The midline was then split and we began the dissection on the from medial to lateral. There were X# medial row perforators that were identified. We decided to base the flap off the medial vs lateral row due to the size, position 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.  
 + 
 +We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. The selected perforators were followed through the rectus fascia and the rectus muscle, meticulously clipping, ligating, and dividing all small side branches. These vessels were followed down to their origin from the inferior epigastric artery and vein, which in turn were followed down toward their origin from the external iliac artery and vein.  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. Flap viability was confirmed and then the donor vessels were clipped and divided. The harvested flap was then flushed with heparinized saline. The flap weight was recorded. 
 + 
 +We then brought the flap to the contralateral chest and secured it to the chest wall. The IM vessels and DIEP pedicle vessels were then prepared under the microscope. We then used a X diamater mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis using standard microsurgical technique. The flap was well perfused with a doppler signal in the pedicle and on the skin.  The previous mastectomy flap edge of skin was debrided based on its damaged appearance. This full thickness skin debridement was performed over a total length of  X cm. The skin paddle was measured and tailored to match the native NAC position both in size and location. 
 + 
 +The flap was then inset after we had de-epithelialized the portion of the buried flap with facelift scissors. Careful attention was paid to in setting the flap without an twist or kink in the perforators or pedicle and this was confirmed with the flow coupler sound. Approximately a 42mm NAC skin paddle was created for future nipple reconstruction. A electrocautery scoring was performed into the flap in order to allow the skin paddle to match the mastectomy with no step-off. 2-0 vicryl suture were used to secure the flap to the chest wall in the anatomically correct position and improve shape. A 15 blake drain was then placed secured with 2-0 nylon and the flap inset with 3-0 and then 4-0 moncryl sutures. 
 + 
 +We then turned our attention to the contralateral flap with a near identical procedure. 
 + 
 +The rectus muscle split was repaired with 2-0 vicryl in a figure of eight. The rectus fascia defect was then closed with buried interrupted 0 PDS in an figure of eight fashion. A running 0 PDS was used to tighten the closure. Two 15 blake drains were then placed.  All drains were secured with 2-0 nylons and a biopatch. The skin was then closed with a 2-0 vicryl for Scarpa's fascia and 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 slightly above the ASIS in an anatomically ideal position. The umbilicus was then inset with 3-0 monocryl deep dermal sutures and 4-0 monocryl in a running fashion. The skin was then dressed with dermabond and prineo. A Pravena incision VAC was placed to assist with healthy wound healing on the abdomen. 
 + 
 +The patient tolerated the procedure well and without complication. She was brought to the PACU in stable condition. At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.  
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 + 
 +==== DIEP Revision ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Right breast reduction for symmetry; left breast reconstruction revision major; fat grafting to left breast 170cc from bilateral medial thighs; abdominal scar revision 8cm\\ 
 +\\ 
 +The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks as well as a wise pattern breast reduction using a standard template. Her DIEP flap was also marked for a reduction in skin paddle and elevation as well as the donor site for fat grafting from bilateral ankles. We also marked the small bilateral standing cone deformities on the abdominal incision.\\ 
 +\\ 
 +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 with chloroprep and draped in the standard fashion.\\ 
 +\\ 
 +For the standing cone deformities we performed a scar revision over a total length of 8cm accounting for both sides. These were resected with a 15 blade then cautery. This was closed with 3-0 and 4-0 monocryl and dressed with dermabond.\\ 
 +\\ 
 +A 42mm cookie cutter was used to mark a new ideal nipple areolar complex size on the right breast.  A 8 cm wide superomedial pedicle was then de-epithelialized using 10 blade. The superomedial pedicle was then dissected away from the surrounding breast tissue down to the chest wall using electrocautery. The nipple was pink and viable during this process.  I then removed the medial, lateral and inferior breast tissue from the wise pattern outline.  Once the resected specimen was removed the skin was tailor tacked with a stapler. 15cc of  0.5% Marcaine with 1:200,000 epinephrine was infiltrated in the pectoralis major muscle fascia for perioperative analgesia. A total of X g of tissue were resected from the right breast. The IMF, vertical limbs and periareolar incision were then closed with 3-0 monocryl into the dermis followed by a 4-0 running monocryl intracuticular.  Dermabond was then applied all incisions with Prineo to the IMF and T junction.\\ 
 +\\ 
 +I then turned my attention to the contralateral breast. The downsizing of the left skin paddle was performed to produce a symmetric 42mm reduction. The mastectomy flaps were undermined completely to help elevate and medialize the flap. The DIEP flap was completely repositioned superiorly and medially. There was a T junction of skin which needed to be resected on the mastectomy flaps in order to achieve this result. The patient was sat in an upright sitting position to assess for size, shape, and symmetry of the breasts.  All necessary adjustments were subsequently made to achieve excellent symmetry. Meticulous hemostasis and copious irrigation was then performed.\\ 
 +\\ 
 +I then turned my attention to fat grafting. Her donor sites were marked in preop - bilateral medial thighs.  I infiltrated X cc of standard tumescent solution after making a small incision with a 11 blade into each thigh.  After waiting a suitable period of time I then began lipoaspiration.  Great care was taken to avoid deep suction and to avoid contour deformity.  The fat was collected sterilely and prepared using the Revolve system   I then placed the fat in sterile syringes for injection.  The incisions were closed with 5-0 fast gut. A total of X cc of fat were initially harvested.\\ 
 +\\ 
 +I then added total of X cc of fat graft to the left breast. This was infiltrated as per Coleman technique in the previously marked areas of deficit in the superomedial areas of her breast reconstruction as well as symmetrically throughout the whole flap for greater volume.  The injection sites were closed with a 5-0 fast gut.  These incisions were dressed with steristrips and opsite dressings.\\ 
 +\\ 
 +She was placed into ACE wraps for the legs. \\ 
 +\\ 
 +The nipples were viable at the end of the procedure and the breasts soft.  She was placed into a surgical bra with ABDs. The patient tolerated this procedure without complication, and postoperatively she was extubated and brought to the recovery room in stable and satisfactory condition.\\ 
 +\\ 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\Post-operative care: Include restrictions, splints, etc...\\Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Brachioplasty ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Bilateral brachioplasty\\ 
 +\\ 
 +The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks as well as an elliptical excision pattern of the bilateral upper arms.\\ 
 +\\ 
 +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 with chloroprep and draped in the standard fashion.\\ 
 +\\ 
 +A near identical procedure was performed on both arms.\\ 
 +\\ 
 +After markings were confirmed anterior incisions were made with a 15 blade scalpel. No axillary Z-plasty or dissection was needed based on patient habitus. Dissection with electrocautery was subsequently performed down to biceps and triceps muscle fascia.  Careful attention was paid to stay above the fascia and leave a small amount of tissue at this plane.  Once a significant amount of tissue had been elevated and markings were confirmed for ease of closure at the posterior skin incision was also made.  This was also dissected down to the level of the muscle fascia.  The medial antebrachial cutaneous nerve was not found with in the wound due to the posterior position of the incision.  Meticulous hemostasis was obtained throughout the operation.  Once initial resection was performed bilaterally the resulting contour was compared for symmetry on both sides using tailor tacking with staples. We confirmed a symmetry and anatomically harmonious result with minor additional alterations. The wounds were then irrigated with antibiotic saline.\\ 
 +\\ 
 +Final resection weights:\\ 
 +\\ 
 +30cc of 0.25% Marcaine with 1:200,000 epinephrine was infiltrated in the skin incision. A 15F round drain was placed into each wound and sutured in position with a 2-0 Nylon. The Scarpas layer was closed with 2-0 vicryl in an interrupted fashion. The deeper dermis was closed with a 2-0 PDO V-loc and the superficial dermis and epidermis was closed with a running 3-0 monocryl. Dermabond was then applied all incisions. The wound was dress with Telfa, Kerlix and ACE wraps from the hand to axilla\\ 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: 2X 15F round drains\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== ALT Free Flap ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Anterolateral thigh flap 7 x 15 cm to right lateral foot. Intraoperative SPY angiography to assess perfusion.\\ 
 +\\ 
 +The patient was taken to the operating room and placed supine on the operating room table. The right lower extremity was prepped and draped in standard, sterile fashion.  Preoperative time-out was performed confirming site and laterality, patient, procedure to be performed, and IV antibiotics.\\ 
 +\\ 
 +Following this, attention was first turned to the wound.  The margin of necrotic skin was excised with a #15 blade scalpel circumferentially including a small portion of glabrous skin.  There was bleeding tissue at the margin and exposed bone, therefore, a piece of this bone was sent for pathology.  Skin, subcutaneous tissue, fascia, down to and including bone was then debrided 7 x 5 cm.  The site was copiously irrigated.  This was templated out onto an elliptical pattern for an ALT and the intervening skin to the AT and DP vessels was excised keeping intact the underlying fascia covering tendon.  This was then transposed onto his right thigh in the site of a perforator for an ALT 7 x 15 cm. Anterior incision was made down to crural fascia.  LFCN was identified, carefully preserved.  Single perforator was identified.  This was traced through an intramuscular course in the descending branch of the lateral and femoral circumflex artery.  Five-thousand units of IV heparin were given.  The flap was islandized and brought down to the foot. The flap was cut back on the pedicle given the position so that a end-to-side into the DP with the perforator was completed, with 9-0 nylon, and a vein within each branch draining both comitantes into a single outflow was coupled into comitantes of the DP with a 2-0 coupler.  Clamps removed, demonstrated excellent flow.  The flap was inset with 3-0 nylon.  The thigh was closed by repairing the muscle with 3-0 PDS.  The skin was then closed with 3-0 nylon over a #15 round Blake drain.\\ 
 +\\ 
 +Following this, the flap appeared well perfused.  Good Doppler signal on a Vioptix marker and therefore a well- padded dressing was applied.  He was awoken from anesthesia, and transported to the PACU in stable condition. 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== VRAM ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Vertical rectus abdominis flap\\ 
 +2. Complex closure\\ 
 +3. SPY fluorescence angiography\\ 
 +4. Exploratory laparotomy closure\\ 
 +\\ 
 +The patient was brought into the operating room and placed in the lithotomy 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 conclusion of the colorectal surgery team as well as the gynecological oncology team resections, I was called into the OR, the defect was extensive and had a large pelvic volume requirement. The initial size of the wound was approximately ? cm x ? cm of the pelvic floor.  There was a small cuff of vagina remaining as well.  The defect was reassessed and a 8 cm skin island was needed over the entire vertical length of the rectus muscle. 
 + 
 +I then began the flap elevation of the right VRAM. A 8 cm wide VRAM was designed around the periumbilical perforators. The skin was incised using a blade and and dissected down to the anterior rectus sheath using electrocautery.  Of note this patient did have a significant adipose layer.  The flap was then dissected carefully using cautery along the rectus sheath until the medial and lateral row of perforators was encountered. This maneuver was performed to preserves as much fascia as possible for abdominal closure. Once these were located the anterior the rectus fascia was incised and the rectus muscle was immediately encountered.  The flap was then elevated from distal to proximal dividing the muscle using cautery.  Using a combination of cautery as well as blunt dissection, the muscle and its skin paddle was elevated to its origin at the deep inferior epigastric system and pubic ramus.  Periodically 2-0 Vicryl sutures were placed in the muscle to secure it to the Scarpa's fascia to prevent shearing of the flap.  The pedicle was protected in its entirety.  
 + 
 +Once the flap was completely elevated, 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 was subsequently passed into the pelvis to enable it to travel with minimal tension on the pedicle and perforators.  The skin paddle was marked based on the defect.  Our goal was to reconstruct as much of the posterior vaginal wall as possible while still providing dead space fill to the pelvis and a tension-free closure on the APR defect.  The proximal portion of the skin was de-epithelialized and the flap was passed carefully into the pelvis for inset. The flap passed easily into the perineum with the muscle obliterating the floor of the pelvis. The muscle was inset with 2-0 PDS and a 15 French Blake placed to drain the deep perineal space and sutured to the skin anteriorly using 2-0 nylon. The skin was then inset with 2-0 PDS for scarpa's fascia layer and 2-0 vicryl in a horizontal mattress fashion for the skin.  The posterior aspect of the pelvic resection was able to be closed primarily.  This involved a complex closure of multiple layers including fascia, subcutaneous tissue, dermis, and epidermis using 2-0 PDS as well as 2-0 Vicryl over an entire length of approximately 7 cm. A 15 French Blake drain was also placed into the anterior rectus sheath and sutured to the skin using 2-0 nylon. 
 + 
 +Due to the fact that the Gyn/Onc team as well as the colorectal team was unavailable to close the exploratory laparotomy incision, I elected to perform this portion of the procedure.  A 2-0 PDS suture was used to repair the posterior rectus sheath in a figure of 8 fashion over its entire length.  The anterior rectus fascia was then repaired using a looped 0 PDS.  The deep Scarpa's layer was subsequently repaired with a 2-0 Vicryl in an interrupted fashion.  A 3-0 stratafix suture was used to repair the dermis over the entire length of the incision and a 3-0 Monocryl suture was used as an intracuticular stitch for aesthetic closure of the epidermis.  The wound was subsequently dressed with Dermabond and an OpSite dressing.  The pelvic wound was dressed with fluffs and mesh underpants.  Drains were dressed with bio patches and Tegaderms. 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== FTM Top Surgery ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Bilateral subcutaneous mastectomy and free nipple graft\\ 
 +\\ 
 +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 using chloroprep.   In the preoperative suite the IMF was marked and along with the proposed resection specimen to create a straight transverse resultant scar.  This was confirmed with the patient and great care was taken to ensure that the medial extent of the incision was >2cm from the midline.\\ 
 +\\ 
 +I began with the right breast. A 25mm cookie cutter was used as a template for the new nipple.  The nipple was excised full thickness and the breast tissue and excess soft tissue was removed with sharp iris scissors. The nipple graft was placed in a moist lap pad for later use.  I then made the superior incision.  The superior flap was raised to the chest wall at 1cm of thickness with careful attention to remain evenly in the junction between the subcutaneous tissue and the breast parenchyma. Adequate tissue for closure was confirmed. Once this was completed, the lower incision was made straight down to the chest wall. All excess overhanging skin at the border and irregularities were smoothed out. The breast tissue and skin were then dissected completely off the chest wall from medial to lateral being sure to leave pectoralis and serratus muscle fascia intact. The specimen was passed off to pathology for review per protocol.  The wound was thoroughly irrigated and bleeding controlled using cautery.  A temporary closure with tailor tacked staples was performed.\\  
 +\\ 
 +I then turned my attention to the contralateral breast and the exact same procedure was performed.  The patient was sat upright multiple times to confirm symmetry and ideal male chest contour. A 15 blake drain was placed on each side and secured to the skin using 2-0 nylon suture.  The mastectomy flaps were then advanced to the lower marking with careful attention to keeping the incision as transverse as possible. A 3-point 2-0 vicryl suture was used to tack both the upper and lower flaps to the chest wall. The remainder of the incision was closed with 3-0 and then 4-0 monocryl sutures.\\ 
 + 
 +Mastectomy Weights:\\ 
 +Right:\\ 
 +Left:\\ 
 +\\ 
 +Special attention was paid to the lateral chest wall to remove as much of the standing cone deformity as possible.\\ 
 +\\ 
 +The patient was again placed in the upright position.  The new nipple location was placed in the aesthetic ideal position. This was deemed to be ? cm from the midline and ? cm from the inferior incision. Symmetry was confirmed.  The template was used to de-epithelialize the nipple graft bed and convert the round nipple to a male horizontal oval ideal shape.  This base was well vascularized and the nipple grafts were sutured with 5-0 chromic suture in an interrupted and continuous fashion. The nipple grafts were secured with bolster dressings of cotton balls, mineral oil, and xeroform using 2-0 silk sutures. The incisions were then dressed with dermabond, op site and an abdominal binder to the chest. The drains were dressed with bio patchs and tegaderm.\\ 
 +\\ 
 +The patient tolerated the procedure well and without complication and was transferred to recovery in stable condition.\\  
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: 15 blake drain x2\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== TE to Implant ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Bilateral breast reconstruction revision for asymmetry, bilateral tissue expander removal and silicone implant placement. Scar revision bilateral breast 12cm in total length for both sides.\\ 
 +\\ 
 +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.  A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision.\\ 
 +\\ 
 +Identical procedures were performed on both sides. The previous IMF scars were full thickness excised using a 15 blade scalpel based on their thickness.\\ 
 +\\ 
 +Dissection of the mastectomy flaps was made above the fold using electrocautery to create a stair-step for entry into the pocket.  The capsule was subsequently entered in a stairstep location at a higher aspect of the breast.  The current tissue expander was removed and inspected and determined to be intact without evidence of infection or rupture.  The capsule was also opened medially and superiorly to better accommodate the implant size and allow a better contour. Specifically on the left breast the IMF was lowered by 1 cm and opened medially and superiorly. The left pocket was also revised to remove nonviable Alloderm and opened superiorly and medially. Initially sizers were placed into the pocket.\\ 
 +\\ 
 +Patient was set up multiple times to confirm symmetry.  Once we were happy with excellent symmetry the pockets were irrigated with Betadine and antibiotic irrigation.  Meticulous hemostasis was performed.  The skin was recleansed with Betadine.  Using a new set of gloves new implants were placed with careful attention not to touch the skin.\\ 
 +\\ 
 +Once the implants were in position and properly seated the capsule was closed with a 2-0 Vicryl in interrupted fashion. The deeper dermis was closed with a 3-0 Monocryl in the superficial dermis and epidermis were closed with a 4-0 Monocryl.  The wound was subsequently cleansed again and dressed with Dermabond. Dressings consisted of a surgical bra with ABDs. 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Breast Implant Removal ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Breast tissue expander removal and drain placement\\ 
 +2. Scar revision\\ 
 +3. Washout of breast \\ 
 +\\ 
 +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 using chloroprep.\\ 
 +\\ 
 +I opened up the breast prior incision with a 15 blade and noted a moderate amount of purulence concerning for infection. A culture was taken for microbiology. We then washed out the pocket thoroughly using pulse lavage with 3L of saline. Hemostasis was performed throughout the pocket thoroughly. A rim of inflamed nonviable skin was removed as a scar revision. A 15F blake drain was placed onto the right side and secured to the skin using 2-0 nylon suture.  The incision was subsequently closed with with 3-0 and then 4-0 monocryl sutures.\\ 
 +\\ 
 +The incisions were then dressed with dermabond, ABDs and an bra. The drains were dressed with bio patchs and tegaderm.   
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Tissue Expander (Pre-pectoral) ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Bilateral breast reconstruction with tissue expander (pre-pectoral) and acellular dermal matrix\\ 
 +\\ 
 +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.  A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision. Please refer to the breast surgeon's op note for full details of the mastectomy. 
 +\\ 
 +Mastectomy Weight: R g; L g\\ 
 +\\ 
 +At the time that I was called into the OR, the mastecomies had been completed.  I began with the right side - the mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery.  I then irrigated the pocket with saline and measured the breast footprint. Two sheets of 16 X 8cm had been prepared as per manufacturers guidelines was then were then sutured together ex-vivo using 2-0 vicryl. Gloves were exchanged and an expander was placed into the ADM and completely wrapped circumferentially (deflated) using 2-0 vicryl.  The suture tabs were exposed through small openings. The pocket was again irrigated with betadine and saline. We prepped the skin with betadine. The completely wrapped TE with ADM was then sutured to the chest wall with 2-0 Vicryl in the proper orientation and position.\\ 
 +\\ 
 +The tissue expander was filled to ? cc of sterile saline using the port such that there was minimal tension on mastectomy flap skin.\\ 
 +\\ 
 +Hemostasis was then confirmed again and the pocket irrigated with saline. Two 15 blake was placed and sutured with a 2-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl intracuticular.\\ 
 +\\ 
 +I then turned my attention to the contralateral breast. The exact same procedure was performed on that side.\\   
 +\\ 
 +The wounds were cleansed and dressed with Biopatches for the drains and dermabond applied to the incisions.  She was placed into a surgical bra with fluffs.  She was extubated and transferred to recovery in stable condition.   
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 +Subpectoral tissue expander using alloderm. He says that the breast should be one thumb width apart. That's the cosmetically pleasing position of breast implants. This allows for cleavage, obviously. He uses 2-O vicryl in order to sew in the tissue expander as well as sew the alloderm to the muscle. He then uses 3-0 and 4-0 monocryl in order to close the skin. 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Tissue Expander sub-pectoral with ADM ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Breast reconstruction with tissue expander and acellular dermal matrix\\ 
 +\\ 
 +Expanders \\ 
 +R:  133S-MV-T cc; SN #\\ 
 +L:  133S-MV-T cc; SN #\\ 
 + 
 +Alloderm Lot #:\\ 
 +R: \\ 
 +L: \\ 
 + 
 +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.  A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision. Please refer to the breast surgeons op note for full details of the mastectomy.\\ 
 +\\ 
 +Mastectomy Weight: g\\ 
 +\\ 
 +At the time that I was called into the OR, the mastecomies had been completed.  I began with the right side - the mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery.  I then irrigated the pocket with antibiotic saline.  The pectoralis was then elevated and divided at its inferomedial origin.  The perforators were controlled with cautery and medium clips.  A sheet of alloderm which had been prepared as per manufacturers guidelines was then placed into the wound.  It was then inset to the IMF and lateral breast border with a 2-0 vicryl. I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine.  Gloves were exchanged and an expander was placed into the pocket (deflated).  The suture tabs were sutured to the chest wall with 2-0 Vicryl. I then closed the interface between the pectoralis and acellular dermal matrix with a 2-0 vicryl in a running fashion.  The tissue expander was filled with sterile saline using the port such that there was minimal tension on the pectoralis muscle pocket or mastectomy flap skin. 
 +\\ 
 +Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline.  One 15 blake was placed and sutured with a 2-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl intracuticular.\\   
 +\\ 
 +I then turned my attention to the contralateral breast. The exact same procedure was performed on that side.\\ 
 +\\ 
 +The wounds were cleansed and dressed with Biopatches for the drains and dermabond applied to the incisions.  She was placed into a surgical bra with fluffs.  She was extubated and transferred to recovery in stable condition.\\ 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: 15F Blake drain for each side\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 + 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 + 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Split Thickness Skin Graft ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Preparation of wound bed\\ 
 +2. split thickness skin graft\\ 
 +3. wound vacuum placement\\ 
 +\\ 
 +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 sterile fashion. \\ 
 + 
 +The operation began with preparation of the wound bed. The skin edges were debrided with ? to remove all non viable tissue over the entire wound .   The wound was then debrided of excess granulation, retained vac sponge, and debris with gentle scrapping. 3 liters of normal saline was used as lavage with cysto tubing. \\ 
 + 
 +A template was created and then transferred to the thigh and a dermatome set at 12 one thousandth of an inch thickness was used to obtain a STSG.  The skin graft was then meshed at 1:1.5.  It was placed on the wound bed and secured with staples and 4-0 chromic suture. A VAC dressing was then applied over adaptec and the graft then placed at 125mmHg continuous. Minimal leak was noted. Of note this VAC was an inpatient version which is durable medical equipment and not disposable and will remain in position for 5 days while the patient is admitted to the hospital. The lower leg was then wrapped with a loose kerlix and ACE warp. The donor site was managed with mepliex dressing and then wrapped with a large ACE.  
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: Type of drain and placement\\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\Post-operative care: Include restrictions, splints, etc...\\Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 +==== Spine Closure ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +Operative Report:\\ 
 +1. Reconstruction of spinal defect with bilateral paraspinous muscle flap closure vs complex wound closure and incisional VAC placement\\ 
 + 
 +Upon completion of spine surgery's portion of the case including but not limited to proper positioning, padding, and monitoring, plastic surgery commenced our portion of the case.  The wound was examined closely and the defect was identified. The wound was 15 cm in length. We initially irrigated and meticulous hemostasis was obtained.  Based upon the significant hardware and close proximity to the spine this was deemed appropriate for muscle flap coverage of this area.  The plane was made above the paraspinal muscles in the superior aspect of the incision using Bovie electrocautery. The left paraspinal muscles were identified and the anterior investing fascia was dissected to the lateralmost border. The segmental perforating blood supply over the posterior intercostals was identified.  Release of the lateral fascia was performed using cautery with care not to damage the neurovascular structures. The paraspinal muscle were then freed to transport medially.  The goal of the muscle release was to transport both muscles medially to allow for closure of dead space as well as to provide a tension-free closure of muscular tissue overlying the hardware.\\   
 +\\ 
 +An identical procedure was performed on the right side. \\ 
 +\\ 
 +The wound was again examined for any bleeding and meticulous hemostasis was obtained. We then placed a 2 hemovac drains below the muscular layer.  The paraspinal muscles were then sewn to themselves in the midline using a 0 PDS suture using a figure-of-eight fashion.  This was done over the entire length of the wound and muscle. This enabled good vascularized tissue coverage over the hardware.  There was also 2 X 15 French Blake drains placed into the soft tissue fields.  Drains were sewn into position using a 3-0 nylon suture.  The Scarpa's fascia was repaired with a 2-0 PDS suture.  The deep dermis was repaired with a 3-0 Monocryl suture and the superficial dermis and epidermis were repaired with a 3-0 nylon in a running horizontal mattress fashion.  At the conclusion of the procedure all the wound edges are well approximated and the drains were holding suction.   
 +  
 +The skin was subsequently cleansed again and it was dressed with Biopatch as for the drains. The 15 cm incision had a durable medical equipment incisional VAC placed with the use of the hemovac drains being placed into a sponge after adaptec was placed on the wound. This was covered with occlusive dressing and attached to a wound VAC and 125mmHg. 
 +  
 +The sponge and instrument counts were correct and the patient tolerated the procedure well and he subsequently transported to the PACU in stable condition and will be followed by the plastic surgery service. 
 + 
 + 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Photos\\ 
 + 
 +Tourniquet: finger / forearm / arm\\ 
 +Drain: 2 X 15F French round drains and deep wound drain and incisional VAC \\ 
 +Sutures: List all layers\\ 
 +Dressing: What's preferred?\\ 
 + 
 +Anatomy: Pertinent anatomy should be listed\\ 
 +Post-operative care: Include restrictions, splints, etc...\\ 
 +Learning points/Pimp Questions:\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 + 
 + 
 + 
 + 
 + 
 + 
 + 
 + 
 + 
 + 
 + 
 +==== Panniculectomy ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 +\\ 
 +Operative Report\\ 
 +1. Panniculectomy with umbilical transposition\\ 
 +\\ 
 +I marked the patient in the preoperative suite while standing. A high lateral tension approach was utilized to reduce dog ears. The lower incision was made above the mons pubis and in a dumbbell shape laterally with the maximum amount of resection marked.\\ 
 +\\ 
 +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.\\  
 +\\ 
 +The umbilicus was dissected free from the abdominal skin using a 15 blade scalpel. Dissection was carried down to the abdominal wall being sure to leave adequate tissue to maintain perfusion. A larking stitch was placed into the umbilicus for future placement onto the abdominal wall. Next the lower abdominal incision was made with a 10 blade and then carried to just above rectus fascia with bovie electrocautery.  Many large superficial veins were encountered and controlled with a combination of surgical clips and electrocautery.  Dissection was carried cephalad to the superior incision which was above the umbilicus.  I then confirmed that we could close the wound with a reasonable tension with a small amount of retroflex of the bed. The superior extent of the incision was then marked and incised. The pannus was then removed after all the bleeding vessels were controlled. Weight of specimen ~1500g.  The wound was irrigated copiously with saline and meticulous hemostasis was confirmed. 30cc of 0.5% marcaine was added into the abdominal wall for post operative pain control. The upper abdominal skin was then tailor tacked closed. 2X19F drains were placed into the wound and secured with 2-0 nylon sutures laterally. The Scarpa's fascial layer was then closed with with 2-0 vicryl. The dermis was closed with interrupted 3-0 monocryl.  The epidermis was then closed with an intracuticular 4-0 monocryl.\\  
 +\\ 
 +The umbilicus was then delivered through a new opening on the abdominal skin making sure not to twist it. This was secured in position with 3-0 monocryl and 4-0 fast gut. The wounds were subsequently dress with Prineo and Biopatches to the drain sites. The patient was then placed in an abdominal binder with ABDs for padding.\\ 
 + 
 +The patient tolerated the procedure well and without complication. She was brought to PACU in stable condition.\\ 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Drains: 2 X 19F round blake drains brought at lateral edge of incision\\ 
 +Sutures: Drains 2-0 nylon, SFS 2-0 vicryl, Skin:3-0, 4-0 monocryl. Umbilicus: 3-0 monocryl, 4-0 fast gut.\\ 
 +Dressing: Abdomen: prineo, Umbilicius dermabond, drains: biopatch and tegaderm, ABDs, Binder.\\ 
 +Markings: High lateral tension approach. Markings are dumbbell shaped.\\ 
 + 
 +{{:resident:867e5bc2-68e8-48f3-9e09-3bcbb0f1e16d.jpeg?400|}} 
 +{{:resident:210376a6-f2aa-4d02-b9ac-13a42a0fc4ff.jpeg?400|}} 
 + 
 +Resident Notes:\\ 
 +The high lateral tension approach changes the area of greatest tension to about the 1/3rd mark of the incision and off midline. The dumbbell shape helps decrease dog ears. Dr. Cohen will mark the maximum that you can cut with his pre-op markings. In the OR, you will have to remeasure and will not get that far. Remember that the area of greatest tension is not in the middle and you are lateralizing the upper part of your skin flap.\\ 
 + 
 +Questions you will be asked:\\ 
 +If you can't close your incision what are your options? More reflex, more undermining superiorly and inferiorly, progressive tension suturing, incisional wound vac. Wedge out flap subcutaneous tissue.\\ 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 +==== Abdominoplasty/Liposuction ==== 
 + 
 +<WRAP group> 
 +<WRAP half column> 
 + 
 +place holder for op report 
 + 
 +</WRAP> 
 +<WRAP half column> 
 + 
 +{{:resident:whatsapp_image_2020-05-10_at_4.51.55_pm.jpeg?400|}}
  
 +</WRAP>
 +</WRAP>
  
-==== Tissue Expander ==== 
-Subpectoral tissue expander using alloderm. He says that the press should be one thumb width apart that's cosmetically advantageous position of breast implants. This allows for cleavage, obviously. He uses 2-O vicryl in order to sew in the tissue expander as well as sew the alloderm to the muscle. He then uses 3-0 and 4-0 monocryl in order to close the skin. 
  
resident/justin_cohen.1571513020.txt.gz · Last modified: 2019/10/19 15:23 by jonathan
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