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--- resident:justin_cohen [2020/08/16 14:06] – [Direct to Implant Breast Recon] jonathan
+++ resident:justin_cohen [2020/08/16 19:26] (current) – [Operative Reports] jonathan
@@ Line 17: / Line 17: @@
 ===== Operative Reports =====
+General Tips:\\
+\\
+==== Breast Reduction (Superiomedial Pedicle) ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. 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:\\
+. 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:\\
+**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>
+==== Nipple Reconstruction ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. 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:\\
+. 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:\\
+.  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:\\
+. 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:\\
+. Perineal reconstruction with gracilis flap\\
+. 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:\\
+. 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:\\
+. 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:\\
+. 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:\\
+. 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:\\
+. 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 ====
@@ Line 101: / Line 566: @@
 Post-operative care: Include restrictions, splints, etc...\\
 Learning points/Pimp Questions:\\
+</WRAP>
+</WRAP>
+==== DIEP Revision ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. 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>
@@ Line 377: / Line 885: @@
 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>
@@ Line 504: / Line 1013: @@
-==== Breast Reduction Procedure====
-**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 \\
-**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 \\
-==== 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.
 ==== Panniculectomy ====