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--- resident:justin_cohen [2020/08/16 14:18] – [Operative Reports] 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 ====
@@ Line 23: / Line 338: @@
 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.\\
@@ Line 570: / 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 697: / 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 ====