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--- resident:tae_chong [2019/09/19 13:24] – [Blepharoplasty] jonathan
+++ resident:tae_chong [2021/02/22 09:36] (current) – [Facial Artery Dissection] michael
@@ Line 1: / Line 1: @@
-===== Introduction =====
+===== Dr. Tae W Chong Introduction =====
-Dr. Tae Chong. Intro.
-Operations below. He very much enjoys asking [[resident:pimp_questions|Questions]]. Here are Dr. Chong's [[resident:expectations|Expectations]] and tips for meeting them.
+[[https://drive.google.com/open?id=1BmQYXNhAOHBFNVsgACDK_n42880pMWYx|Dr. Chong Publications Link]]\\
+[[https://drive.google.com/open?id=1-P9w2iJQ-zffK6oNDKieQn0kNuUYvwo6|Dr. Chong Recommended Papers]]
+Degrees:
+  * Bachelor of Science, Biology 8/90 – 6/94, College of William and Mary, Williamsburg, VA
+  * Doctor of Medicine 8/96 – 6/00, University of Virginia, Charlottesville, VA
-===== Breast Reconstruction =====
+Training:
+  - General Surgery Internship, Categorical 7/00 – 6/01, University of Chicago, Chicago, IL
+  - General Surgery Residency, Categorical 7/01 – 6/07, University of Virginia, Charlottesville, VA
+  - Research Fellow, Transplantation &amp; Infectious Disease 7/02 - 6/04, University of Virginia, Charlottesville, VA
+  - Plastic and Reconstructive Surgery 7/07 – 6/10, University of Pittsburgh Medical Center, Pittsburgh, PA
+  - Associate Program Director Plastic Surgery Residency 2011 - 2015 at UTSW
-Know Base Width in chart and what patient desires for breast size (smaller, same, fuller).\\
+Research Interests:\\
+. Clinical reconstructive transplantation – evaluating hand transplant outcomes and optimizing medical
+management of the recipient.\\
+. Surgical Management of Lymphedema\\
+. Outcomes in the reconstruction of cancer and post-traumatic defects.\\
+. Surgical and adjuvant therapy for the treatment and prevention of hypertrophic scars and keloids.\\
-Scrub: For any implant cases, Chong requires you to first scrub and then use Avaguard.\\
+Interests and Activities: Marathons, obstacle races, soccer, and martial arts.
-==== BBA, Lipo, Abdominoplasty ====
-Preop Dx:  Breast ptosis, abdominal lipodystrophy, abdominal diastasis
-Procedure:  Bilateral breast augmentation, liposuction of abdomen, and abdominoplasty
-Drains:  15 blake x2 in the abdomen
-I marked the position of the lower incision and the scar for the patient in preop.
+=====Operating Reports=====
-Operative Report
+General Tips:\\
-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.
+[[medical_student:diep_post-op_protocol|Dr. Chong's DIEP Post-Op Protocol]]\\
-I began with the left breast.  An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion.  The pocket was irrigated with abx saline and multiple sizers were placed.  The sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I turned my attention to the contralateral breast.
-An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion.  The pocket was irrigated with abx saline and multiple sizers were placed.  The sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I placed the patient in a sitting up position.  This gave the best appearance and correction of her hypoplasia and ptosis.
+===== Breast Reconstruction =====
-The sizers were removed and I prepped the skin with betadine.  Both pockets were irrigated with abx saline and hemostasis was confirmed.   Everyone exchanged gloves and using the minimal touch technique the silicone implants were placed bilaterally.  The breast capsule was then closed with a 3-0 PDS in an interrupted fashion.  The skin was closed with 3-0 and then 4-0 monocryl sutures.  dermabond was applied.
+Know Base Width in chart and what patient desires for breast size (smaller, same, fuller).
+Scrub: For any implant cases, Chong requires you to first scrub and then use Avvaguard to fill tissue expander, first put it undrr water and suck out sll of the air with filler needle and suctuon vac dont forgrt to make fold in TE  dr chong uses high profile  has 3 bladders and preferentially fills lower pole   roll TE like a joint  place the TE and then fit the alloderm in after it is set  for dissection of lifting left major off chest wall, lift with browns and go in the fuzzies  the pedicle is sitting in that fat, so once you’re over pect minor, get under the fat and right on top of pect minor and blunt dissect up.    Bovie25/25 to prevent the thermal injury
-I then turned my attention to the abodmen.   Both flanks were infiltrated with wetting solution and after waiting a suitable period of time, liposuction was performed of bilateral flanks.  Great care was taken to avoid contour deformity by changing the angles and using crosshatching techniques.  I then turned my attention to the abodminoplasty.  The lower abdominal incision was made with a fresh 10 blade.  The dissection was carried down to the fascia with bovie electrocautery.  The SIEV and SIEA branches were all controlled with cautery and surgical clips.  The abdominal flaps were then elevated to the level of the umbilicus.  The umbilicus was then incised with a 11 blade and the stalk dissected to the abdominal wall.   At this point we continued our elevation to the xiphoid process.  The intercostal and rectus perforators were controlled with cautery and surgical clips.
-I then identified the area of diastasis and repair.  This was marked and the diastasis was corrected with 0 nurolon sutures in an interrupted figure of 8 fashion.  The wound was then irrigated and hemostasis was confirmed.  The patient was then placed into a flexed position and the upper abdominal flap was advanced to the lower to determine the skin resection.  This was marked and the skin was excised with a 10 blade and bovie cautery.  The incision was temporarily closed with staples using our vertical plum lines made in preop as reference points.  The site for the umbilicus was identifed and marked.  I then defatted the area of the umbilicus.
+==== Infected or Exposed Breast Implant ====
-I then placed 2 blake drains (15) with exit points at the lateral incision.  The wound was irrigated and hemostasis confirmed.  I then closed the SFS with 2-0 vicryl in an interrupted fashion.  The skin was then closed with 3-0 and then 4-0 monocryl suture.  Dermabond was then applied and the drains were secured.  I then cut out the position of the umbilicus with a 15 blade and delivered it through the abdominal wall.  It was inset with 4-0 monocryl deep dermal sutures and dermabond. The patient was then placed into a surgical bra and a surgical binder and extubated without difficulty.
-==== Breast Augmentation ====
-Preop Dx:  Breast ptosis, hypomastia
-Procedure:  Bilateral breast augmentation
-Drains:  None
-Brief Clinical History
+==== Latissimus Muscle Flap ====
-@NAME@ is a pleasant @AGE@ female with deflational changes to her breasts who would like more volume and correction of the ptosis.  We discussed the use of breast implants in correcting this in select patients.  She may need a mastopexy at some point later if this doesn't adequately address the ptosis.  We discussed the risks of bleeding, pain, infection, damage to surrounding structures, scarring, asymmetry, disability, loss of implant, capsular contracture and need for further surgery.
+<WRAP group>
+<WRAP half column>
-I marked the position of the lower incision and the scar for the patient in preop.
+Drains: Donor site: 15 blake\\
+Sutures: Deep dermal 3-0 monocryl, Subcuticular 4-0 monocryl\\
+Dressing: Donor site: Prevena Vac\\
-Operative Report
+An incision was made from the axilla to the back along the axis of the latissimus muscle.  Dissection was carried to the muscle.  The latissimus was then circumferentially dissected.  The pedicle was identified at its entry into the muscle and the tendinous insertion of the flap was divided under direct visualization.  The pedicle was dissected out and divided.   The donor site was then irrigated with normal saline and then closed over a 15 blake drain with 3-0 monocryl suture for the deep dermal layer followed by a 4-0 monocryl suture for the subcuticular layer.  The flap was flushed with heparinized and dangled over the wound to allow the pedicle to untwist.
-The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
-I began with the left breast.  An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion (He chooses which dual plane to use).  The pocket was irrigated with abx saline and multiple sizers were placed.  The  sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I turned my attention to the contralateral breast.
+</WRAP>
-An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion.  The pocket was irrigated with abx saline and multiple sizers were placed.  The sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I placed the patient in a sitting up position.  This gave the best appearance and correction of her hypoplasia and ptosis.
+<WRAP half column>
-The sizers were removed and I prepped the skin with betadine.  Both pockets were irrigated with abx saline and hemostasis was confirmed.   Everyone exchanged gloves and using the minimal touch technique the silicone implants were placed bilaterally.  The breast capsule was then closed with a 3-0 PDS in an interrupted fashion.  The skin was closed with 3-0 and then 4-0 monocryl sutures.  dermabond was applied and the patient was taken to recovery in a surgical bra.
+{{:resident:screen_shot_2020-04-13_at_4.11.34_pm.png?400|}}
-Know Base Width in chart and what patient desires for breast size (smaller, same, fuller).  Scrub: For any implant cases, Chong requires you to first scrub and then use Avvaguard to fill tissue expander, first put it undrr water and suck out sll of the air with filler needle and suctuon vac  dont forgrt to make fold in TE  dr chong uses high profile  has 3 bladders and preferentially fills lower pole   roll TE like a joint  place the TE and then fit the alloderm in after it is set  for dissection of lifting left major off chest wall, lift with browns and go in the fuzzies  the pedicle is sitting in that fat, so once you’re over pect minor, get under the fat and right on top of pect minor and blunt dissect up.    Bovie25/25 to prevent the thermal injury
+</WRAP>
+</WRAP>
+==== DIEP ====
+<WRAP group>
+<WRAP half column>
-====Tissue Expander====
+Preop Dx:  history of breast cancer, s/p mastectomy and now with deformity and disproportion\\
-Dr. Chong expects you to know: Nipple sparing vs skin sparing and reasoning (e.g. tumor close to nipple, ptotic breast), Base Width, History of radiation or plan for radiation, type of cancer\\
+Procedure: 1.  Bilateral breast reconstruction with DIEP flaps -  S code\\
+(22 modifier if S code not applicable, muscle preservation and length of dissection)\\
+.  SPY fluorescence imaging of skin perfusion based on perforator dissection\\
+Drains: 2 drains in the donor site and one drain in each breast\\
-Important Notes: Only Dr. Chong opens and handles the tissue expander. “Double” scrub (betadine, dry hands, avaguard) and double gloves. Will switch gloves before handling tissue expander. Dr. Chong does not fill the tissue expander intraoperatively.\\
+**Operative Report**\\
+We utilized a two team approach. My partner exposed the mammary vessels. \\
-Placement order: If subpectoral, pectoralis muscle dissected, TE sutured in place before alloderm placed and sutured. If pre-pectoral, two pieces of alloderm sutured superiorly and inferiorly and then tissue expander placed before final closure of alloderm. The reasoning behind this is that Dr. Chong has switched to smooth expanders and they don't stay in place like textured implants and he treats them like DIP.\\
+Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the pectoralis - bilaterally.   We started on the irradiated side first.  We then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.\\
-Sutures: 3-0, 4-0 monocryl closure, Alloderm 3-0 PDS, drain stitch 3-0 nylon\\
-Irrigation: 1L baci irrigation with cysto tubing\\
-Drain: 15 blake drain placed over pectoralis/alloderm\\
-Dressing: Dermabond, 1 inch steristrips cut over each tail of subcuticular, biopatch tegaderm, ABD pad, Bra\\
-Pre-operative markings: Bilateral IMF, meridian, also makes transverse markings at the level of the IMF but midline and lateral as to mark the level of the IMF incase it is obliterated during mastectomy portion, breast footprint.
+Why dissect SIEV 6cm? because it's in the dot phrase. Ribs. Take a rib or otherwise you are doing a vertical anastamosis. Lever up with rouncher. Never point freer towards vessels. Always towards cartilage/perichondrium. \\
-In the preoperative suite, I marked the IMF and the breast footprint on her chest wall. We also discussed drains.\\
+We then dissected out the vessels on the contralateral side.  We identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.\\
-Operative Report 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 Dr. ???' s op note for full details of the mastectomy.
+During this time we began the flap elevation portion of the operation by making the superior incision.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for 6cm. The flap dissection was then carried down to the rectus fascia.\\
-At the time that I was called into the OR, the mastectomies had been completed. I began with the {LEFT/RIGHT/SIDE:304012941} 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. I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine. Gloves were exchanged and a ??? expander with a ???cm BD was placed into the pocket (deflated). The suture tabs were sutured to the chest wall with 3-0 PDS. A sheet of??? size??? 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 running 3-0 PDS. I then closed the interface between the pectoralis and Alloderm with a 3-0 PDS in a running fashion.
+We then elevated the flap from lateral to medial. The lateral row had x perforators and we then made the midline incision. An oval incision was made around the umbilicus and carried down to the fascia. //Dr. Chong excises the belly button with two single pronged skin hooks (placed superior and inferior) and then cuts with an 11-blade down a straight line. He completes the cuts where the skin hooks were with a 15-blade.// 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 x row due to the size and quality.  The x row was clamped with atraumatic clamps.  The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines. //3cc's and a 10 cc flush.// The flap perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise. \\
-Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline. One15 blake was placed and sutured with a 3-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl pull-out suture.
+We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  This added an additional 2 hours to each side.  The x row perforators were then clipped and divided and the remainder of the dissection was then performed.\\
-I then turned my attention to the contralateral breast. 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. I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine. Gloves were exchanged and a ??? expander with a???cm BD was placed into the pocket (deflated). The suture tabs were sutured to the chest wall with 3-0 PDS. A sheet of ???? size ? 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 running 3-0 PDS. I then closed the interface between the pectoralis and Alloderm with a 3-0 PDS in a running fashion
+We then brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a x mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin.  The flap was then inset after we had de-epithelialized the portion of the buried flap.  A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.\\
-Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline. One 15 blake was placed and sutured with a 3-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl pull-out suture. Biopatches were placed on 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.
+We then turned our attention to the contralateral flap which was elevated  from lateral to medial. The lateral row had x perforators and the medial row had x perforators. We decided to base the flap off the x row due to the size and quality.  The x row was 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.\\
-. Know BW and fill levels as well as radiation\\
+We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  The x row perforators were then clipped and divided and the remainder of the dissection was then performed.\\
-Radiation will change the nipple position and skin color\\
-. Use old incisions\\
-Dissect to capsule/alloderm. Alloderm will form new IMF\\
-. Make new incision in capsule that is offset from skin incision (approximately 8mm-1cm superior)\\
-. Cut sutures to TE. Puncture and then take it out.\\
-. Pick your implant. The most important factor is Base-width. Try to match with TE.\
-. Put the sizer in to check that you like it\\
-. take out the sizer. \\
-. Irrigate the pocket\\
-. betadyne the skin\\
-. Betadyne all instruments from now on\\
-. Put in implant\\
-. Close the capsule, bury knots\\
-. Close the skin 3-0, 4-0 monocryl\\
-. Dermabond incision and steristrip tails.\\
-. Finish one side before starting the other.\\
-To fill tissue expander, first put it under water and suck out all of the air with filler needle with vac suction. Don't forget to make the fold in TE so it doesn't obstruct the filling port.\\
+We then brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a x mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin. The flap was then inset after we had de-epithelialized the portion of the buried flap.  A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.\\
-Dr. Chong likes using high profile TE which have 3 bladders and preferentially fill the lower pole\\
-roll TE like a joint place the TE and then fit the alloderm in after it is set\\
-For dissection of lifting pectoralis major off chest wall, lift with browns and go in the fuzzies the pedicle is sitting in that fat, so once you’re over pect minor, get under the fat (the pectoral arterial branch is in that fat) and right on top of pect minor and blunt dissect up.\\
+The rectus fascia defect was then closed with buried 0 prolene in an interrupted figure of eight fashion. Two 15 blake drains were then placed.  All drains were secured with 3-0 nylons and a biopatch. The SFS was then closed with 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer. The skin was closed with 4-0 running subcuticular suture. The umbilicus was then incised on the abdominal wall the the umbilical stalk delivered. The umbilicus was then inset with 4-0 monocryl deep dermal sutures. The skin was then dressed with dermabond and the patient was placed into an abdominal binder.\\
-Bovie25/25 to prevent the thermal injury\\
-==== Breast Fat Grafting ====
+At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.
-Suture: 4-0 chromic simple interrupted to close stab incisions for liposuction and fat grafting.\\
-Dressing: Bacitracin and band-aid over each site.\\
-I had a long discussion about the risks of the surgery including bleeding, pain, infection, contour deformity, injury to the skin, recurrence, wound healing problems, damage to surrounding tissue, and need for further surgery.  The patient understands that she will have to wear compression garments for the postoperative care, and I want her to ambulate daily.\\
+Bed: **Make sure the bed is able to reflex appropriately before the case**
+Drains: 15 blake (2 in abdomen, 1 in each breast)\\
+Sutures:\\
+Arterial anastomosis - 9-0 nylon\\
+Vein anastomosis - vein coupler\\
+Anterior abdominal fascia - 0 prolene\\
+Breast inset and abdominal closure - 3-0 monocryl deep dermal, 4-0 monocryl subcuticular\\
+Belly button - Make 2cm vertical by 1cm transverse oval and 3-0 monocryl deep dermal, as needed 4-0 monocryl half-buried "U" sutures (inside belly button to avoid suture marks on skin)\\
+All Drains: 3-0 nylon\\
+Dressings:\\
+Breast: light bacitracin over inset incisions, Steri-strips over wire, tegaderm over vein coupler white connector piece, if vioptix, dermabond\\
+Belly Button: dermabond (no xeroform)\\
+Abdomen: Provenia\\
+All Drains: Tegaderm, biopatch\\
-Operative Report\\
+Drapes: Blue towels and staples, 4 folding sheets, ioban strips\\
-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. \\
-Her donor sites were marked in preop  I infiltrated cc of wetting solution after making a small incision with a 11 blade.  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 as per closed Revolve system   I then placed the fat in sterile syringes for injection.  The incisions were closed with 4-0 chromic.\\
+Abdominal Dissection: Has said contradictory points in past... 1. He bevels up towards the head for each of the incision so that the fat lines up nicely. 2. Has said keep fat on the flap. And in the corners, make sure to leave the fat on the flap to prevent a dog ear.\\
+Dissect the DIEV back to the "H" of the vein before transecting. There is usually a crossing point as the two branches of DIEV come back together. Honestly this looks more like an upside down "A." Basically in turns into a Y with a crossing path in it. IF you are past the cross, you're far enough.\\
-I then made several stab incisions on the  breasts.  A total of XXX cc of fat graft was then infiltrated as per Coleman technique in the previously marked areas of deficit in the areas of her breast reconstruction.  The injection sites were closed with a 4-0 chromic.  She was placed into a binder and surgical bra after dressings were placed on the incisions.\\
-===== Aesthetics =====
+Elevates umbilicus by placing 2 single-prong skin hooks superiorly and inferiorly and pulling up. Uses an 11-blade to incise around the umbilicus then uses cautery to extend incision down to the fascia. Does not mark it with a suture. When closing skin, find the umbilical stalk and mark corresponding spot on the skin. Draw out a 2x1 cm oval over the umbilical stalk and excise. Pull umbilicus through the hole and secure with interrupted 3-0 sutures. Only place ½ buried 4-0 monocryl horizontal mattress sutures in places that need reinforcement. Secure with dermabond.
-==== Blepharoplasty ====
+Take a rib or otherwise you are doing a vertical anastamosis. Lever up with rouncher. Never point freer towards vessels. Always towards cartilage/perichondrium.
-Preop Dx:  Bilateral upper lid dermatochalasis\\
+Questions you will be asked:
-Procedure:  Bilateral upper lid blepharoplasty\\
+Why dissect SIEV 6cm? because it's in the dot phrase. The primary drainage system of the abdomen is the superficial system (not the DIEV), so it's a good bailout option. It could also potentially be used as vein graft.
-Anesthesia:  GETA\\
-Drains:  none\\
+</WRAP>
-In the preoperative suite, I marked the upper lid crease which was at least 8mm above the ciliary margin and did not extend the markings more medial than the punctum.  The amount of skin resected was then pinched and marked.  All markings were performed with the patient upright.  Moreover, there was greater than 1cm of skin between the upper line and the brow.
+<WRAP half column>
-Operative Report
+Tourniquet: No\\
-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.
+Drain: 15 blake drain\\
+Sutures: 9-0 nylon suture for the arterial anastomosis, flap inset with 3-0 and 4-0 moncryl sutures, drains secured with 3.0 nylons and biopatch. 2-0 vicryl followed by a 3.0 monocryl for the deep dermal layer. 4-0 running subcuticular suture. 4-0 moncryl deep dermal sutures.\\
+Dressing: dermabond\\
-Corneal protectors with ophthalmic bacitracin were placed.  I then infiltrated both incisions with 1% lidocaine with epi - (3cc total for both lids).  I began with the right upper lid.  Using a fresh 15 blade the skin was incised and removed taking great care to preserve the orbicularis.  I then cauterized any bleeding with a Colorado tip bovie.  The wound was then irrigated and was hemostatic.  The wound was then closed with interrupted 6-0 prolene sutures.
-I then turned my attention to the contralateral lid.  Using a fresh 15 blade the skin was incised and removed taking great care to preserve the orbicularis.  I then cauterized any bleeding with a Colorado tip bovie.  The wound was then irrigated and was hemostatic.  The wound was then closed with interrupted 6-0 prolene sutures.
-The corneal protectors were removed and the eyes washed with HBSS.  The patient was then extuated without complications.   At the conclusion of the procedure, both eyes were easily closed without any scleral show.
+</WRAP>
+</WRAP>
-==== Panniculectomy ====
-Preop Dx:  Panniculitis, excess abdominal skin\\
-Procedure:  panniculectomy\\
-Anesthesia:  GETA\\
-Drains:  ???\\
-The risks included bleeding, pain, infections, damage to surrounding tissue, seroma, wound healing problems, need fur further surgery, loss of umbilicus, and unattractive scarring.  Informed consent was obtained.
+==== IMA Exposure ====
 Operative Report
-The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
-I had marked the patient in the preoperative suite.  The lower incision was above the mons pubis and tapered laterally.  The incision was made with a 10 blade and then carried to the 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 below the umbilicus.  I then confirmed that we could close the wound with towel clamps and then made the superior skin incision.  The pannus was then removed after all the bleeding vessels were controlled and passed off to pathology.  The wound was irrigated and the hemostasis was confirmed.  I then closed the SFS layer with 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer.  The skin was then closed with 4-0 monocryl.  The skin was dressed with ???.   Prior to closure the patient had two 15 blake drains placed with exit sites laterally .
+<WRAP Group>
+<WRAP half column>
+A two team approach was used for the operative exposure and flap elevation.  I began with the SIDE chest.  The prior scar was incised and taken down to the pectoralis muscle and alloderm.  The skin flaps were raised to the borders of the new breast mound/extent of tissue expansion.  Once this was completed, the capsule was incised and the expander removed.  I then performed a capsulectomy and the pectoralis muscle was sutured down to the chest wall with 3-0 pds suture in an interrupted figure of eight fashion.
+I then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  I 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.  I then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.
+First I made the flaps. Of course, you go on top of the muscle and you go up to the upper pole of the breast medial to where you're going to do your rib dissection and inferior to the IMF. Don't go too far out laterally or the flap will shift. First divide the muscle over the third rib. You straddled the rib with two fingers and Bovie in between. Get a really big wide dissection and then once you're on the peri-condrium, score it with the Bovie to start and then use your elevator to go along with the peri-condrium. Don't make holes, use the sharp side, but keep it facing towards the cartilage so that you don't accidentally go through it and hurt the vessels.
+You'll have to divide the intercostal muscles in order to make space for the dissection. Dr. Chong goes rib to rib so that you're able to have a long length of vessels for your anastomosis. Also, he makes the point every freaking time, which sides harder. The left side's harder, nobody knows why, but the right side has bigger vessels. The artery is lateral to the vein and the right side tends to have two veins rather than one and they tend to split and then the veins will straddle the artery. Once you take the peri-condrium down, you can then rongeur the cartilage, made sure not to go through the posterior side of your elevated peri-condrium, and you could always fix the little pieces at the end with the elevator rather than trying to take the little pieces off with the rongeur. Once you're through there, you start as lateral as you can with the monopolar and start lifting up the peri-condrium from the vessels, the vessels are incased in very vascular lymphatic tissue.
-==== Abdominoplasty ====
+These are highly vascular and can bleed so you really got to be vigilant about making sure that you're controlling your field and you follow the intercostal muscles down and lift the peri-condrium that you elevated off of the vessels lateral to medial. You will be bridging vessels from the intercostal artery and vein that will cross over your IMA and IMV. Make sure to control these vessels.
-Pre-op: Mark the position of the lower incision and the scar\\
-Position: Supine\\
-Prep: "Tuck and roll"\\
-Antibiotics: Yes, indicated. Ancef. If penicillin allergy, vancomycin.\\
-Steps: Lower abdominal incision was made with a fresh 10 blade. The dissection was carried down to the fascia with bovie electrocautery.  The SIEV and SIEA branches were all controlled with cautery and surgical clips.  The abdominal flaps were then elevated to the level of the umbilicus.  The umbilicus was then incised with a 11 blade and the stalk dissected to the abdominal wall.   At this point we continued our elevation to the xiphoid process.  Intercostal and rectus perforators were controlled with cautery and surgical clips.
-I then identified the area of diastasis.  This was marked and the diastasis was corrected with 0 Nurolon sutures in an interrupted figure of 8 fashion.  The wound was then irrigated and hemostasis was confirmed.  The patient was then placed into a flexed position and the upper abdominal flap was advanced to the lower to determine the skin resection.  This was marked and the skin was excised with a 10 blade and bovie cautery.  The incision was temporarily closed with staples using our vertical plum lines made in preop as reference points.  The site for the umbilicus was identified and marked.  I then defatted the area of the umbilicus.
+For the IMA dissection which vessel is lateral and which is medial? The artery is lateral and the vein is medial. This is important because you're going to be dissecting from lateral to medial and then you're going to have to be going under the rib under the sternum even to get to the vein, and this is the one that's much more fragile.
-I then placed 2 blake drains (15) with exit points at the lateral incision.  The wound was irrigated and hemostasis confirmed.  I then closed the SFS with 2-0 vicryl in an interrupted fashion.  The skin was then closed with 3-0 and then 4-0 monocryl suture.  Steristrips were applied and the drains were secured.  I then cut out the position of the umbilicus with a 15 blade and delivered it through the abdominal wall.  It was inset with 4-0 monocryl deep dermal sutures and dermabond. The patient was then placed into a surgical binder and extubated without difficulty.
+It's in a harder place to dissect and it's at more risk for injury at this medial location. The right side is usually bigger. So the right side's easier to dissect origin of the IMA. Origin of IMA is the subclavian artery. The deep inferior epigastric artery origin is the distal external iliac artery.
-===== Other Microsurgery =====
+</WRAP>
+<WRAP half column>
-==== PT Dissection ====
+Tourniquet: No\\
-The medial malleolus was marked and an incision was made just posterior to this and connecting to the wound. Prior to this the tourniquet was insufflated to 250mmHg pressure. Dissection was carried down to the fascia and the fascia was divided with electrocautery. The interval between the superficial and deep posterior compartments was developed. The fascia overlying the PTA in the deep posterior was opened sharply. Dessection was then carried circumferentially around the PTA and veins. Great care was taken to identify the PT nerve and preserve it. Once the PTA and veins were prepared, we then brought the ??? flap into the wound.
+Drain: No\\
+Sutures: 3-0 pds suture\\
+Dressing: No\\
-==== Gracilis Muscle Flap to Perineum ====
-Procedure: gracilis muscle flap to perineum, SPY indocyanine green fluorescence angiography\\
-Markings: Frog leg patient. Adductor longus should be bowed out muscle and mark entire course to knee. Mark gracilis 2 finger breadths below
-Drains: 15 blake in thigh and 10 blake in the perineum\\
-Sutures: Thigh: 3-0 monocryl, 4-0 monocryl, Perineum 3-0 PDS to parachute in muscle, 3-0 vicryl to close perineum (because it is less prickly than PDS)\\
-Dressings: Dermabond or steristrips depending on if Dr. Chong wants to hide scar for thigh. Tegaderm biopatch for drains, ace wrap for thigh, but don't go too high to compress tunnel. Bacitracin and ABD for perineum
-Restrictions: POD#0 bedrest. ABduction pillow while in bed. POD#1 okay to mobilize with PT/OT. Should walk with legs shoulder width apart. No ABduction of surgical extremity.\\
-Operative Report
+</WRAP>
-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.
+</WRAP>
+==== DIEP Revision Implants ====
-At the time that I was called into the room the anus had been removed and a small dead space existed. The wound was reassessed and hemostasis obtained with cautery and surgical clips. I then turned my attention to the harvest of the gracilis muscle.
+<WRAP Group>
+<WRAP half column>
-A curvilinear incision was made just posterior to the axis of the adductor longus muscle. This was carried down to the muscle fascia and great care was taken to preserve the GSV. The fascia was then opened and the gracilis muscle was identified. This was taken to the insertion and divided with cautery. The branches from the SFA were controlled with surgical clips and divided. The flap was then raised from proximal to distal. I then identified the skin perforator and this was divided. The pedicle was seen just deep to this and the dissection was stopped. I then made a tunnel to the perineum in the subcutaneous plane. Tunnel is appoximately 3 chong fingers in width. He also divides the SFS to prevent bands that would compress the pedicle.
+Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction with DIEP flaps
+Procedure:  Revision breast reconstruction with fat grafting
+Breast implant placement under DIEP flaps
+Anesthesia:  GETA
+Drains:  None
+Implants:  Left:   ???
+Right: ???
+Brief Clinical History
+female with a history of breast reconstruction.  Due to the mastectomy defect and differences in mastectomy flaps, radiation on ???, differences in soft tissue settling, and donor site asymmetry, she has contour irregularities, deformity and asymmetry that need to be addressed surgically for breast reconstruction.  We outlined the scar location together in preop.   We discussed using breast implants to improve the shape and projection of the DIEP flaps.
+I had a long discussion about the risks of the surgery including bleeding, pain, infection, contour deformity, injury to the skin, recurrence, wound healing problems, damage to surrounding tissue, capsular contracture, loss of implants, damage to the flap, rare association with ALCL, and need for further surgery.  The patient understands that she will have to wear compression garments for the postoperative care, and I want her to ambulate daily.
+Operative Report
+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.
+I began with implant placement on the ???.  The IMF incision was made and carried to the chest wall.  The flap was then elevated with a precise pocket for the implant.  There was a dense and fibrotic capsule under the flap and capsulotomies were performed.  Hemostasis was confirmed and the pocket irrigated with abx saline.  Several implant sizers were placed and the best fit with good breast aesthetics was the Mentor SR??? implant ??? cc.  The pocket and skin were temporarily closed and I turned my attention to the contralateral breast.
+The IMF incision was made and carried to the chest wall.  The flap was then elevated with a precise pocket for the implant. Hemostasis was confirmed and the pocket irrigated with abx saline.  Several implant sizers were placed and the best fit with good breast aesthetics was the  Mentor SR??? implant ??? cc, similar to the contralateral side.  The pocket and skin were temporarily closed and there was excellent symmetry.  The sizers were removed and the pockets irrigated with abx saline.  Hemostasis was confirmed.  The skin was reprepped with betadine and the entire team exchanged gloves.  The implants were then placed (Mentor SR??? implant ??? cc).  The capsule was then closed with 3-0 PDS in an interrupted figure of 8 fashion.  The skin was closed with 3-0 and then 4-0 monocryl sutures.  Dermabond was applied to the wound.
+Her abdominal donor sites for the fat grafting were marked in preop.  I infiltrated ???cc total of wetting solution after making a small incision with a 15 blade near each site.  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 from the ???.  The Revolve system was utilized for fat harvesting in the closed system.   I then placed the fat in sterile syringes for injection.  The incisions were closed with 4-0 chromic sutures.
+I then turned my attention to the breasts.  The areas of deficit in the ??? breast had been marked in preop.  I made several stab incisions on the breasts (away from the decolletage).  The fat graft was then infiltrated as per Coleman technique  in the previously marked areas of deficit in the superomedial pole of her breast recon on the left.  The injection sites were closed with a 4-0 chromic suture.  The incisions were all dressed.
+She was placed into a surgical bra and binder after dressings were placed on the incisions.
-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.
+</WRAP>
+<WRAP half column>
-The gracilis was then passed into the perineum and inset into the perineal dead space. It was inset circumferentially with 3-0 pds sutures. The superficial fascia and muscle were then reapproximated with a 3-0 pds. The skin was then closed with 3-0 pds in an interrupted fashion. A 10 blake drain was placed into the perineum.
+Tourniquet: No\\
+Drain: No\\
+Sutures: 3-0 PDS in an interrupted figure 8 fashion. Capsule closed with 3-0 and then 4-0 monocryl sutures. Incisions were closed with 4-0 chromic sutures.\\
+Dressing: Dermabond\\
-The donor leg was then irrigated and hemostasis confirmed. A 15 blake drain was placed and the deep dermal layer was closed with 3-0 monocryl. The skin was then reapproximated with 4-0 monocryl. The wound was dressed with dermabond.
-The patient is to be transferred with the Right leg ADDUcted at all times and a dry abd pad on the perineum and sacrum at all times (changed qid).
+</WRAP>
+</WRAP>
-Pimp questions:
+==== Tissue Expander Exchange for Implants ====
-. What superficial vein may you encounter during dissection? Greater saphenous vein
+<WRAP group>
-. What is the blood supply to the gracilis muscle? It is a type II muscle flap. Dominant pedicle is branch of medial femoral circumflex artery. It cannot survive off SFA perforators. Pedicle AND skin perforator approximately 10 cm from pubic symphsis.
+<WRAP half column>
-. Describe course of medial femoral circumflex artery? Between adductor magnus and longus.
-. What nerve supplies the gracilis muscle? anterior branch of obturator.
+Preop Dx:  ??? breast mastectomy, history of ?\\
+Procedure:  ??? breast TE exchange, \\
+Surgeons:  Tae Chong, MD\\
+Anesthesia:  GETA\\
+Complications:  none\\
+Findings:   Well healed expander pocket\\
+Drains:  None\\
+Implants: R ???\\
+L ????\\
-==== Gracilis Free Flap ====
+ history of ??? breast mastectomy reconstructed with TE and ADM.   She was seen in clinic and after adequate expansion she was found to be a good candidate for exchange.  We discussed her desire to be as symmetric as possible with the contralateral breast and a natural silhouette
-Procedure:  Perineal reconstruction with gracilis flap
-SPY indocyanine green fluorescence angiography
-Surgeons:  Tae Chong, MD
-Anesthesia:  GETA
-Findings:   Well vascularized gracilis flap, obliteration of the dead space
-Drains:  15 blake drain in each thigh
-Benefits: Vascularized muscle in promoting wound healing, especially in irradiated fields.
-I had a long discussion with the patient about the goals of reconstruction.  The purpose of utilizing a flap is to bring in well vascularized tissue to promote wound healing.  The risk of the gracilis flap as with any reconstruction includes bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, need for drain, donor site numbness, wound healing problems, loss of flap, and need for further surgery.
+I also had a discussion with her about the need for capsulotomies for lower pole expansion and to utilize superomedial capsulotomies for the chest wall to breast recon transition.
-Informed consent was obtained.
+We discussed the risks of TE exchange which can include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, need for further surgery, capsular contracture, and loss of implant.
 Operative Report
-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.
+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.
+In the preoperative suite I marked the IMF on both sides and the location of the capsulotomies. I began with the ???breast. The prior mastectomy scar was incised and the dissection taken to the capsule with bovie cautery. The capsule was divided and the expander was deflated. I then removed the expander.  I then placed several implant sizers, and the closest was the ??? implant ???? cc.  The lateral breast contour was confirmed with palpation. The capsule was temporarily closed and the skin stapled.
+I then turned my attention to the contralateral breast. The prior mastectomy scar was incised and the dissection taken to the capsule with bovie cautery. The capsule was divided and the expander was deflated. I then removed the expander. I then placed several implant sizers, and the closest was the ??? implant ??? cc.   The lateral breast contour was confirmed with palpation. The capsule was temporarily closed and the skin stapled. She was placed into a sitting position to confirm size, shape, and symmetry. The implants were removed.
+I then irrigated the pocket copiously with antibiotic irrigation. We exchanged gloves and the skin was reprepped. The implants were then placed into the pocket confirming the orientation. I then closed the capsule with 3-0 PDS in an interrupted fashion. The skin was closed with 3-0 monocryl and then with a running pullout 4-0 monocryl.
+Dermabond was applied and the patient was placed into a surgical bra. The patient was extubated and transferred to recovery in stable condition.
-I began with the SIDE 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.
+Surgical Steps:\\
+. Know BW and fill levels as well as radiation\\
+Radiation will change the nipple position and skin color\\
+. Use old incisions\\
+Dissect to capsule/alloderm. Alloderm will form new IMF\\
+. Make new incision in capsule that is offset from skin incision (approximately 8mm-1cm superior)\\
+. Cut sutures to TE. Puncture and then take it out.\\
+. Pick your implant. The most important factor is Base-width. Try to match with TE.\
+. Put the sizer in to check that you like it\\
+. take out the sizer. \\
+. Irrigate the pocket\\
+. betadyne the skin\\
+. Betadyne all instruments from now on\\
+. Put in implant\\
+. Close the capsule, bury knots\\
+. Close the skin 3-0, 4-0 monocryl\\
+. Dermabond incision and steristrip tails.\\
+. Finish one side before starting the other.\\
+</WRAP>
+<WRAP half column>
-==== DIEP ====
+Tourniquet: No\\
-Drains: 15 blake (2 in abdomen, 1 in each breast)\\
+Drain: No\\
-Sutures:\\
+Sutures: 3-0 monocryl, running pullout 4-0 monocryl\\
-Arterial anastomosis - 9-0 nylon\\
+Dressing: Dermabond\\
-Vein anastomosis - vein coupler\\
-Anterior abdominal fascia - 0 prolene\\
-Breast inset and abdominal closure - 3-0 monocryl deep dermal, 4-0 monocryl subcuticular\\
-Belly button - Make 2cm vertical by 1cm transverse oval and 3-0 monocryl deep dermal, as needed 4-0 monocryl half-buried "U" sutures (inside belly button to avoid suture marks on skin)\\
-All Drains: 3-0 nylon\\
-Dressings:\\
-Breast: light bacitracin over inset incisions, Steri-strips over wire, tegaderm over vein coupler white connector piece, if vioptix, dermabond\\
-Belly Button: dermabond (no xeroform)\\
-Abdomen: Provenia\\
-All Drains: Tegaderm, biopatch\\
-Drapes: Blue towels and staples, 4 folding sheets, ioban\\
-Preop Dx:  history of breast cancer, s/p mastectomy and now with deformity and disproportion\\
+</WRAP>
-Procedure: 1.  Bilateral breast reconstruction with DIEP flaps -  S code\\
+</WRAP>
-(22 modifier if S code not applicable, muscle preservation and length of dissection)\\
+==== Top Surgery ====
-.  SPY fluorescence imaging of skin perfusion based on perforator dissection\\
-Drains: 2 drains in the donor site and one drain in each breast\\
-Inset changed due to implantable doppler: \\
-Operative Report\\
+<WRAP Group>
-We utilized a two team approach. My partner exposed the mammary vessels.
+<WRAP half column>
-Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the pectoralis - bilaterally.   We started on the irradiated side first.  We then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.\\
+Preop Dx:  Gender affirmation surgery, top surgery candidate
+Procedure:  Bilateral subcutaneous mastectomy and free nipple graft
+Prevena incisional wound vacuum placement bilaterally (13cm sponge)
+Findings:   Breast tissue removed, hemostatic wound bed, healthy dermal bed for graft
+Drains:  15 blake drain x2
+female with a history of gender identity disorder who has received counseling and medical approval to initiate gender affirmation surgery.  She met all the WPATH guidelines.
+The risks of surgery include but are not limited to bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, wound healing problems, loss of free nipple graft, complete loss of sensation of the nipple, contour problems and need for further intervention.
+Operative Report
+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.   In the preoperative suite the IMF was marked and tapered superolaterally to contour with the lateral pectoral border.  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 left breast tissue.  The superior incision was confirmed by tailor tacking.   I then used a 20cc syringe plunger as a template for the new NAC (2.5cm in diameter).  The nipple was excised full thickness and the breast tissue and excess soft tissue was removed - the nipple graft was placed in a moist lap pad.  I then made the superior incision.  The superior flap was raised to the chest wall at 1cm of thickness.   The breast tissue was completed, the lower incision was made and the breast tissue and skin were passed off to ps then taken off the pectoralis fascia and the dissection carried down past the IMF, obliterating the IMF.     The wound was irrigated and bleeding controlled using cautery and surgical clips.  A 15 blake drain was placed.  The mastectomy flap was then advanced to the lower marking and closed with 3-0 and then 4-0 monocryl sutures.
+I then turned my attention to the contralateral breast.  The superior incision was confirmed by tailor tacking.   I then used a 20cc syringe plunger as a template for the new NAC (2.5cm in diameter).  The nipple was excised full thickness and the breast tissue and excess soft tissue was removed.  The nipple graft was placed in a moist lap pad.I then made the superior incision.  The superior flap was raised to the chest wall at 1cm of thickness.   The breast tissue was then taken off the pectoralis fascia and the dissection carried down past the IMF, obliterating the IMF.  Once this was completed, the lower incision was made and the breast tissue and skin were passed off to pathology.   The wound was irrigated and bleeding controlled using cautery and surgical clips.  A 15 blake drain was placed.  The mastectomy flap was then advanced to the lower marking and closed with 3-0 and then 4-0 monocryl sutures.
+I then placed the patient in the upright position.  The new nipple location was placed at the lateral pectoral border at the 4th intercostal space.  Symmetry was confirmed.  The template was used to de-epithelialize the nipple graft bed.  This was well vascularized and the nipple grafts were sutured with 4-0 chromic suture in an interrupted fashion.  Of note, the grafts were pie crusted to facilitate drainage of the graft bed.  Once this was done, steristrips were placed over the breast incision and the nipple grafts were secured with the small (13cm) Prevena incisional wound vac.  An excellent seal was obtained bilaterally.  The drains were secured with a 3-0 nylon and dressed with bio patch and tegaderm.
-We then dissected out the vessels on the contralateral side.  We identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.\\
+</WRAP>
+<WRAP half column>
-During this time we began the flap elevation portion of the operation by making the superior incision.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for 6cm. The flap dissection was then carried down to the rectus fascia. //Of note, Dr. Chong bevels both the superior and inferior incisions towards the head so the match for closure.//\\
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 3-0 and 4-0 monocryl sutures, 4-0 chromic suture in an interrupted fashion,3-0 nylon\\
+Dressing: bio patch and tegaderm\\
-We then elevated the flap from lateral to medial. The lateral row had x perforators and we then made the midline incision. An oval incision was made around the umbilicus and carried down to the fascia. //Dr. Chong excises the belly button with two single pronged skin hooks (placed superior and inferior) and then cuts with an 11-blade down a straight line. He completes the cuts where the skin hooks were with a 15-blade.// 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 x row due to the size and quality.  The x row was clamped with atraumatic clamps.  The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines. //3cc's and a 10 cc flush.// 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. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  This added an additional 2 hours to each side.  The x row perforators were then clipped and divided and the remainder of the dissection was then performed.\\
+</WRAP>
+</WRAP>
-We then brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a x mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin.  The flap was then inset after we had de-epithelialized the portion of the buried flap.  A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.\\
+==== Unilateral DIEP ====
-We then turned our attention to the contralateral flap which was elevated  from lateral to medial. The lateral row had x perforators and the medial row had x perforators. We decided to base the flap off the x row due to the size and quality.  The x row was 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.\\
+<WRAP Group>
+<WRAP half column>
-We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  The x row perforators were then clipped and divided and the remainder of the dissection was then performed.\\
-We then brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a x mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin. The flap was then inset after we had de-epithelialized the portion of the buried flap.  A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.\\
+Preop Dx:  ??? breast cancer
+Procedure: ??? breast recon with DIEP flaps
+Anesthesia: GETA
+Drains: 2 drains in the donor site and one drain in each breast
+Inset affected by implantable doppler:  ???
-The rectus fascia defect was then closed with buried 0 prolene in an interrupted figure of eight fashion. Two 15 blake drains were then placed.  All drains were secured with 3-0 nylons and a biopatch. The SFS was then closed with 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer. The skin was closed with 4-0 running subcuticular suture. The umbilicus was then incised on the abdominal wall the the umbilical stalk delivered. The umbilicus was then inset with 4-0 monocryl deep dermal sutures. The skin was then dressed with dermabond and the patient was placed into an abdominal binder.\\
+female with a history of breast cancer who presents for ??? mastectomy and reconstruction.
-At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.
+I had a long discussion with her about free tissue transfer for breast reconstruction using abdominal based flaps. The blood supply for the skin and soft tissue is derived from perforators through the rectus abdominis muscle. I will preserve the muscle and limit disability with the perforator dissection. This will have minimal to no functional significance. I outlined the location of the abdominal scars and umbilical scar.
-Why dissect SIEV 6cm? because it's in the dot phrase. Ribs. Take a rib or otherwise you are doing a vertical anastamosis. Lever up with rouncher. Never point freer towards vessels. Always towards cartilage/perichondrium.
+We discussed the need for 24-48 hours of ICU monitoring and the risk of flap loss due to microvascular complications. This occurs 3-5% of the time but if identified early can be salvaged. We also discussed the need to remove costal cartilage for IMA exposure.
+She understands that this is a complex operation but that it offers the best opportunity for a natural ptotic result. We also discussed secondary operations like fat grafting and nipple reconstruction.
-==== IMA Exposure ====
+Operative Report
+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.
-A two team approach was used for the operative exposure and flap elevation.  I began with the SIDE chest.  The prior scar was incised and taken down to the pectoralis muscle and alloderm.  The skin flaps were raised to the borders of the new breast mound/extent of tissue expansion.  Once this was completed, the capsule was incised and the expander removed.  I then performed a capsulectomy and the pectoralis muscle was sutured down to the chest wall with 3-0 pds suture in an interrupted figure of eight fashion.
+Please refer to Dr ???'s note for full details of the mastectomy.Dr Mathes was the co-surgeon for this bilateral free flap due to the complexity and difficulty in DIEP dissection, history of ???, BMI in excess of ???, need for advanced microsurgical expertise and the bilateral nature of the operation.  This operation qualifies for the S code due to the above reasons.
-I then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  I 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.  I then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.
+We utilized a two team approach. Dr. Mathes exposed the mammary vessels.
-==== DIEP Takeback ====
+Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the pectoralis - ???.    We then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.  The artery was at least ??? mm and the vein was ??? mm.
-Consent:\\
+During this time we began the flap elevation portion of the operation by making the superior incision.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for 6cm. The flap dissection was then carried down to the rectus fascia.
-Exploration possible washout\\
-Possible anastamotic revision\\
-Possible saphenous vein harvest and graft\\
-Possible removal of flap\\
-Possible Tissue expander or other salvage procedure\\
+We then elevated the flap from lateral to medial starting on the ??? . The lateral row had ??? perforators.  An oval incision was made around the umbilicus and carried down to the fascia. We then began the dissection on the from medial to lateral. There were ??? medial row perforators that were identified. We decided to base the flap off the ??? row due to the size and quality.  This would be a hemi- flap using the ??? 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.
-Preop Dx:  Venous insufficiency of ??? DIEP flap\\
+We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  This added an additional 2 hours to each side.  The ??? row perforators were then clipped and divided and the remainder of the dissection was then performed.
-Procedure:  Flap washout - reinset\\
-Revision of anastomosis\\
-SPY indocyanine green fluorescence angiography\\
-Anesthesia:  GETA\\
-Drains:  15 blake\\
-She was taken emergently to the OR for flap revision.  We discussed flap revision, need for vein graft, and possible cephalic vein takedown.  She also understands that the flap may require removal and subsequently delayed/staged reconstruction.
-Operative Report
-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 sutures were removed and the flap was de-inset.   There was a ??? amount of ??? blood which was irrigated and aspirated.  The flap was noted to have ??? affecting the venous flow.   We then performed ????.  The flap was re-inset after a new 15 blake drain was placed.  The implantable doppler and the arterial doppler signal were excellent and the skin color was pink.
-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 contrast washed out after 15 minutes confirming venous patency.
-The patient was extubated and taken to recovery in stable condition.
-Only remove A FEW staples if you think there is venous congestion. Hematoma should be handled in OR
+We then brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a ??? mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin.  The flap was then inset after we had de-epithelialized the portion of the buried flap.  A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.
+The rectus fascia defect was then closed with buried 0 prolene in an interrupted figure of eight fashion. Two 15 blake drains were then placed. All drains were secured with 3-0 nylons and a biopatch. The SFS was then closed with 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer. The skin was closed with 4-0 running subcuticular suture. The umbilicus was then incised on the abdominal wall the the umbilical stalk delivered. The umbilicus was then inset with 4-0 monocryl deep dermal sutures. The skin was then dressed with dermabond and the patient was placed into an abdominal binder.
+At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 9-0 nylon suture for the arterial anastomosis, 3-0 and then 4.0 moncryl sutures, buried 0 prolene, 3-0 nylons and a biopatch, 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer, 4-0 running subcuticular suture, 4-0 monocryl deep dermal sutures\\
+Dressing: Dermabond\\
-==== DIEP Revision Implants ====
-Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction with DIEP flaps
-Procedure:  Revision breast reconstruction with fat grafting
-Breast implant placement under DIEP flaps
-Anesthesia:  GETA
-Drains:  None
-Implants:  Left:   ???
-Right: ???
-Brief Clinical History
-female with a history of breast reconstruction.  Due to the mastectomy defect and differences in mastectomy flaps, radiation on ???, differences in soft tissue settling, and donor site asymmetry, she has contour irregularities, deformity and asymmetry that need to be addressed surgically for breast reconstruction.  We outlined the scar location together in preop.   We discussed using breast implants to improve the shape and projection of the DIEP flaps.
-I had a long discussion about the risks of the surgery including bleeding, pain, infection, contour deformity, injury to the skin, recurrence, wound healing problems, damage to surrounding tissue, capsular contracture, loss of implants, damage to the flap, rare association with ALCL, and need for further surgery.  The patient understands that she will have to wear compression garments for the postoperative care, and I want her to ambulate daily.
-Operative Report
-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.
-I began with implant placement on the ???.  The IMF incision was made and carried to the chest wall.  The flap was then elevated with a precise pocket for the implant.  There was a dense and fibrotic capsule under the flap and capsulotomies were performed.  Hemostasis was confirmed and the pocket irrigated with abx saline.  Several implant sizers were placed and the best fit with good breast aesthetics was the Mentor SR??? implant ??? cc.  The pocket and skin were temporarily closed and I turned my attention to the contralateral breast.
-The IMF incision was made and carried to the chest wall.  The flap was then elevated with a precise pocket for the implant. Hemostasis was confirmed and the pocket irrigated with abx saline.  Several implant sizers were placed and the best fit with good breast aesthetics was the  Mentor SR??? implant ??? cc, similar to the contralateral side.  The pocket and skin were temporarily closed and there was excellent symmetry.  The sizers were removed and the pockets irrigated with abx saline.  Hemostasis was confirmed.  The skin was reprepped with betadine and the entire team exchanged gloves.  The implants were then placed (Mentor SR??? implant ??? cc).  The capsule was then closed with 3-0 PDS in an interrupted figure of 8 fashion.  The skin was closed with 3-0 and then 4-0 monocryl sutures.  Dermabond was applied to the wound.
-Her abdominal donor sites for the fat grafting were marked in preop.  I infiltrated ???cc total of wetting solution after making a small incision with a 15 blade near each site.  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 from the ???.  The Revolve system was utilized for fat harvesting in the closed system.   I then placed the fat in sterile syringes for injection.  The incisions were closed with 4-0 chromic sutures.
-I then turned my attention to the breasts.  The areas of deficit in the ??? breast had been marked in preop.  I made several stab incisions on the breasts (away from the decolletage).  The fat graft was then infiltrated as per Coleman technique  in the previously marked areas of deficit in the superomedial pole of her breast recon on the left.  The injection sites were closed with a 4-0 chromic suture.  The incisions were all dressed.
-She was placed into a surgical bra and binder after dressings were placed on the incisions.
+</WRAP>
+</WRAP>
 ==== Direct To Implant ====
+<WRAP Group>
+<WRAP half column>
 Preop Dx:  BRCA gene test positive, s/p bilateral mastectomy
@@ Line 374: / Line 409: @@
 Biopatches were placed on 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.
-==== Facial Artery Dissection ====
- An incision was placed 1.5 cm caudal the the inferior mandibular border along a skin crease.  This was centered over the anterior edge of the masseter and at the palpable site of the facial artery.  Lidocaine with epi 1% was infiltrated into the wound.  A 15 blade was used to make the skin incision and the platysma was divided with electrocautery.
-The superficial cervical fascia was divided sharply and the facial vein was identified.  This was dissected proximally and a second large branch was identified.  They were dissected circumferentially and controlled with vessel loops.  Superficial lymph nodes were then removed to facilitate identification and dissection of the facial artery.   This was dissected circumferentially and controlled with vessel loops.  A lidocaine soaked neuropattie was placed on the vessels until the microvascular anastomosis. The marginal mandibular nerve was identified during the dissection and preserved.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 3-0 PDS, 3-0 mylon, 3-0 monoryl for the deep dermal layer, 4-0 running monocryl pullout suture\\
+Dressing: Biopatches, dermabond\\
-==== Full Thickness Skin Graft ====
+</WRAP>
+</WRAP>
-I discussed with him the risks of full thickness skin graft which include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, loss of skin graft and need for further surgery.  Informed consent was obtained.
-The operation began with preparation of the wound bed.  The skin edges were debrided with a fresh 15 blade down to the level of the wound.  The wound was then debrided of excess granulation, retained vac sponge, and debris with a 10 blade and with 2 liters of antibiotic irrigation delivered with pulse lavage.  I then measured the wound and it was  cm.
-This was then transferred to x and an ellipse was designed.  The full thickness skin graft was obtained and thinned and pie crusted on the back table.  It was placed on the wound bed and secured with 4-0 chromic sutures.  Adaptic, bacitracin, and a wound vacuum were then placed at 75mmHg.   The donor site was closed with 3-0 monocryl deep dermal layer followed by 4-0 monocryl suture.
+==== DIEP Takeback ====
-==== Gastrocnemius Muscle Flap ====
+<WRAP Group>
+<WRAP half column>
-Preop Dx:  Composite wound of the proximal tibia with exposed bone
-Procedure:  Preparation of wound bed x cm, gastrocnemius muscle flap, split thickness skin graft x cm
-SPY indocyanine green fluorescence angiography
-Anesthesia:  GETA
-Findings:   Viable medial gastrocnemius flap
-Drains:  Blake drain
-We had a long discussion regarding the use of gastrocnemius flap transfer for reconstruction.  The risks include bleeding, pain, infection, wound healing problems, damage to surrounding tissue, disability, scarrring, asymmetry, need for further surgery, and partial/ total flap loss.  This occurs in a small percentage of patients, but if caught early can be salvaged with an emergent operation.  We outlined the approach for the flap harvest and for the flap inset.
+Consent:\\
+Exploration possible washout\\
+Possible anastamotic revision\\
+Possible saphenous vein harvest and graft\\
+Possible removal of flap\\
+Possible Tissue expander or other salvage procedure\\
+Preop Dx:  Venous insufficiency of ??? DIEP flap\\
+Procedure:  Flap washout - reinset\\
+Revision of anastomosis\\
+SPY indocyanine green fluorescence angiography\\
+Anesthesia:  GETA\\
+Drains:  15 blake\\
+She was taken emergently to the OR for flap revision.  We discussed flap revision, need for vein graft, and possible cephalic vein takedown.  She also understands that the flap may require removal and subsequently delayed/staged reconstruction.
 Operative Report
-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 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 sutures were removed and the flap was de-inset.   There was a ??? amount of ??? blood which was irrigated and aspirated.  The flap was noted to have ??? affecting the venous flow.   We then performed ????.  The flap was re-inset after a new 15 blake drain was placed.  The implantable doppler and the arterial doppler signal were excellent and the skin color was pink.
+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 contrast washed out after 15 minutes confirming venous patency.
+The patient was extubated and taken to recovery in stable condition.
-I began with debridement of the bony edge and soft tissue to healthy tissue.  The unstable skin and scar were excised with a fresh 15 blade down to bone and fascia to bleeding tissue.  I then irrigated the wound with 3 liters of antibiotic saline.  The appliance was visible in the distal wound but also in the proximal tibia.  Once this was accomplished, I obtained hemostasis.  The leg was then elevated and the tourniquet was insufflated.
+Only remove A FEW staples if you think there is venous congestion. Hematoma should be handled in OR
-I made an oblique incision from the caudal end of the wound to the posterior calf near the midline.  Dissection was carried down to the fascia with electrocautery.  The GSV was identified and controlled with clips then divided.  The crural fascia was divided and the gastrocnemius was identified.  I then developed the plane between the gastroc and soleus muscle, preserving the plantaris with the soleus.  The midline of the gastrocnemius was identified and the lesser saphenous vein was identified and preserved with the remaining lateral gastronemius.  The medial gastrocnemius was then divided from the achilles tendon and elevated distal to proximal.  The muscle fascia was then scored longitudinally to increase the width of the flap.  It was easily inset into the wound covering all exposed appliance and tibia.   The tourniquet was then taken down.
+</WRAP>
+<WRAP half column>
-The flap was then inset with 3-0 pds suture in an interrupted fashion.  A 15 blake drain was placed into the wound and secured with a 2-0 nylon.  The donor site was then closed with 3-0 monocryl followed by 4-0 nylon suture.  I then obtained a ???  cm split thickness skin graft from the right thigh at 12 one thousandth of an inch.  The donor site was dressed with a bio occlusive dressing.  The graft was meshed 1:1.5 and sutured in place with 4-0 chromic.  The wound was then dressed with bacitracin and adaptic.   At the conclusion of the operation, the flap was pink, warm and viable with bleeding from all the edges.
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: No\\
+Dressing: No\\
-==== Gynecomastia ====
-Sutures: 3-0, 4-0 monocryl\\
-Dressing: 1 inch steri strips, compressive ACE or breast binder\\
-Drains: 15 blake round if large resection. Come out lateral and inferior to IMF.\\
+</WRAP>
+</WRAP>
-Preop Dx:  Symptomatic gynecomastia
-Procedure:  Bilateral mastectomy for gynecomastia
-Surgeons: Tae Chong, MD
+==== Gynecomastia ====
-Findings:   Improved shape and contour.  Viable NAC
+<WRAP group>
-Drains:  none
+<WRAP Half Column>
+Preop Dx:  Symptomatic gynecomastia\\
+Procedure:  Bilateral mastectomy for gynecomastia\\
+Surgeons: Tae Chong, MD\\
+Findings:   Improved shape and contour.  Viable NAC\\
+Drains:  none\\
 Pt developed symptomatic gynecomastia which is stable, but has not involuted.  I had a long discussion with the patient about the treatment including liposuction vs direct excision vs elliptical skin and gland removal.  He is most interested in the elliptical incison as it will allow him to resite his nipple and to remove the excess skin.  He understands that with liposuction there will be some skin remodeling, and he would prefer the excisional therapy.
@@ Line 436: / Line 496: @@
 The NAC site was then excised and the nipples delivered.  The nipples were viable and inset with 4-0 and then 5-0 monocryl sutures.  The remainder of the incisions were closed with 3-0 and then 4-0 monocryl sutures.  Dressings were applied followed by an ace bandage and the patient was extubated in stable condition.
-==== Latissimus Muscle Flap ====
+What is saucer deformity? By making a peri-areolar deformity can get a saucer deformity. (Like the indent in a saucer plate for tea).
-Drains: Donor site: 15 blake
-Sutures: Deep dermal 3-0 monocryl, Subcuticular 4-0 monocryl
-Dressing: Donor site: Prevena Vac
-An incision was made from the axilla to the back along the axis of the latissimus muscle.  Dissection was carried to the muscle.  The latissimus was then circumferentially dissected.  The pedicle was identified at its entry into the muscle and the tendinous insertion of the flap was divided under direct visualization.  The pedicle was dissected out and divided.   The donor site was then irrigated with normal saline and then closed over a 15 blake drain with 3-0 monocryl suture for the deep dermal layer followed by a 4-0 monocryl suture for the subcuticular layer.  The flap was flushed with heparinized and dangled over the wound to allow the pedicle to untwist.
+</WRAP>
+<WRAP half column>
-==== Lymphatico venous bypass ====
+Tourniquet: No\\
+Sutures: 4-0 and 5-0 monocryl sutures, 3-0, 4-0 monocryl\\
+Dressing: 1 inch steri strips, compressive ACE or breast binder\\
+Drains: 15 blake round if large resection. Come out lateral and inferior to IMF.\\
-Preop Dx:  Lymphedema of the  arm
+</WRAP>
-Procedure:  SPY indocyanine imaging of lymphatic vessels
+</WRAP>
-Lymphatico venous anastomosis x - 22 modifier, complex due to size of vessels (<1mm) and complex anatomy
+==== BBA, Lipo, Abdominoplasty ====
-Anesthesia:  GETA
+<WRAP Group>
-Findings:   Lymphatic congestion in forearm, prominent lympatic in the middle third of the forearm, patent lymphaticovenous bypass x
+<WRAP half column>
-Drains:  none
-She understands that lymphaticovenous bypass is not a cure, but a treatment adjunct.  She will need to continue to use compression and wraps.   However, she should begin to see symptomatic improvement with better tolerance of the wraps and in some cases will be able to use the sleeves intermittently and not all the time.
+Preop Dx:  Breast ptosis, abdominal lipodystrophy, abdominal diastasis
-The procedure involves decompressing the lympatics into the veins using supermicrosurgery to vessels that are 0.5mm or less.  The surgery is complex, but is performed just under the skin and is performed outpatient.
+Procedure:  Bilateral breast augmentation, liposuction of abdomen, and abdominoplasty
+Drains:  15 blake x2 in the abdomen
-The risks include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, need for multiple procedures, scarring, wound healing problems, worsening of lymphedema, and failure of the bypass.
+I marked the position of the lower incision and the scar for the patient in preop.
 Operative Report
 The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
-I injected 0.1ml of ICG into each webspace and in the wrist and forearm.  SPY technology was used to image the lymphatics.  The hand and distal wrist demonstrated xxx.  In her forearm, there were several areas of congested lymphatics with a marked reticular pattern.  I marked the most prominent lymphatic vessel on the dorsal forearm in the middle third.  I then injected isosulfan blue in the dermal layer just distal to the proposed incision.
+I began with the left breast.  An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion.  The pocket was irrigated with abx saline and multiple sizers were placed.  The sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I turned my attention to the contralateral breast.
-I then wrapped the arm loosely with an esmarch and gently exsanguinated the arm.  A tourniquet was placed to 250mmhg pressure.  An incision was made with a 15 blade.  Dissection was carried through the dermis to the immmediate subdermal layer.  There was a significant amount of fluid and lymphatic congestion.  After exhaustive dissection, a prominent lymphatic vessel was identified with blue dye staining.  This was dissected circumferentially.
+An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion.  The pocket was irrigated with abx saline and multiple sizers were placed.  The sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I placed the patient in a sitting up position.  This gave the best appearance and correction of her hypoplasia and ptosis.
-I then made a small venotomy after placeing microvascular clamps.  The distal end of the lymphatic vessel was then sutured to the vein in an end to ??? manner.  This was performed with 11-0 nylon under maximal zoom under the operating microscope.  After the anastomosis was complete the clamps were removed and the tourniquet was taken down.  There was egress of the isosulfan blue into the vein from the lymphatic vessel.  I then waited 20 minutes to begin the next tourniquet run.
+The sizers were removed and I prepped the skin with betadine.  Both pockets were irrigated with abx saline and hemostasis was confirmed.   Everyone exchanged gloves and using the minimal touch technique the silicone implants were placed bilaterally.  The breast capsule was then closed with a 3-0 PDS in an interrupted fashion.  The skin was closed with 3-0 and then 4-0 monocryl sutures.  dermabond was applied.
-The arm was placed under tourniquet control and another end to side anastomosis was performed to the proximal end of the lymphatic vessel.  This was done with 11-0 nylon in an interrupted fashion.  Of note, dye and lymphatic fluid were present within the vein from the other L-V bypass, confirming the on table patency of the first anastomosis.
+I then turned my attention to the abodmen.   Both flanks were infiltrated with wetting solution and after waiting a suitable period of time, liposuction was performed of bilateral flanks.  Great care was taken to avoid contour deformity by changing the angles and using crosshatching techniques.  I then turned my attention to the abodminoplasty.  The lower abdominal incision was made with a fresh 10 blade.  The dissection was carried down to the fascia with bovie electrocautery.  The SIEV and SIEA branches were all controlled with cautery and surgical clips.  The abdominal flaps were then elevated to the level of the umbilicus.  The umbilicus was then incised with a 11 blade and the stalk dissected to the abdominal wall.   At this point we continued our elevation to the xiphoid process.  The intercostal and rectus perforators were controlled with cautery and surgical clips.
-After this was done the wound was irrigated and hemostasis was obtained.
+I then identified the area of diastasis and repair.  This was marked and the diastasis was corrected with 0 nurolon sutures in an interrupted figure of 8 fashion.  The wound was then irrigated and hemostasis was confirmed.  The patient was then placed into a flexed position and the upper abdominal flap was advanced to the lower to determine the skin resection.  This was marked and the skin was excised with a 10 blade and bovie cautery.  The incision was temporarily closed with staples using our vertical plum lines made in preop as reference points.  The site for the umbilicus was identifed and marked.  I then defatted the area of the umbilicus.
+I then placed 2 blake drains (15) with exit points at the lateral incision.  The wound was irrigated and hemostasis confirmed.  I then closed the SFS with 2-0 vicryl in an interrupted fashion.  The skin was then closed with 3-0 and then 4-0 monocryl suture.  Dermabond was then applied and the drains were secured.  I then cut out the position of the umbilicus with a 15 blade and delivered it through the abdominal wall.  It was inset with 4-0 monocryl deep dermal sutures and dermabond. The patient was then placed into a surgical bra and a surgical binder and extubated without difficulty.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: SFS with 2-0 vicryl in an interrupted fashion, 3-0 and then 4-0 monocryl suture, 4-0 monocryl deep dermal sutures\\
+Dressing: Dermabond\\
+</WRAP>
+</WRAP>
+==== Breast Augmentation ====
+<WRAP Group>
+<WRAP half column>
+Preop Dx:  Breast ptosis, hypomastia
+Procedure:  Bilateral breast augmentation
+Drains:  None
+Brief Clinical History
+@NAME@ is a pleasant @AGE@ female with deflational changes to her breasts who would like more volume and correction of the ptosis.  We discussed the use of breast implants in correcting this in select patients.  She may need a mastopexy at some point later if this doesn't adequately address the ptosis.  We discussed the risks of bleeding, pain, infection, damage to surrounding structures, scarring, asymmetry, disability, loss of implant, capsular contracture and need for further surgery.
+I marked the position of the lower incision and the scar for the patient in preop.
+Operative Report
+The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
+I began with the left breast.  An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion (He chooses which dual plane to use).  The pocket was irrigated with abx saline and multiple sizers were placed.  The  sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I turned my attention to the contralateral breast.
+An IMF incision was made (6cm) and beveled superiorly to protect the IMF.  The lateral border of the pectoralis was identified and a precise pocket was dissected with retraction and cautery.   Perforators were controlled with surgical clips and cautery.  I then divided the inferomedial origin of the pectoralis in a dual plane fashion.  The pocket was irrigated with abx saline and multiple sizers were placed.  The sizer provided the best shape and position on the chest wall.  The pocket was temporarily closed and I placed the patient in a sitting up position.  This gave the best appearance and correction of her hypoplasia and ptosis.
+The sizers were removed and I prepped the skin with betadine.  Both pockets were irrigated with abx saline and hemostasis was confirmed.   Everyone exchanged gloves and using the minimal touch technique the silicone implants were placed bilaterally.  The breast capsule was then closed with a 3-0 PDS in an interrupted fashion.  The skin was closed with 3-0 and then 4-0 monocryl sutures.  dermabond was applied and the patient was taken to recovery in a surgical bra.
+Know Base Width in chart and what patient desires for breast size (smaller, same, fuller).  Scrub: For any implant cases, Chong requires you to first scrub and then use Avvaguard to fill tissue expander, first put it undrr water and suck out sll of the air with filler needle and suctuon vac  dont forgrt to make fold in TE  dr chong uses high profile  has 3 bladders and preferentially fills lower pole   roll TE like a joint  place the TE and then fit the alloderm in after it is set  for dissection of lifting left major off chest wall, lift with browns and go in the fuzzies  the pedicle is sitting in that fat, so once you’re over pect minor, get under the fat and right on top of pect minor and blunt dissect up.    Bovie25/25 to prevent the thermal injury
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 3-0 PDS in an interrupted fashion, 3-0 and then 4-0 monocryl sutures.\\
+Dressing: Dermabond\\
+</WRAP>
+</WRAP>
+====Tissue Expander====
+<WRAP Group>
+<WRAP half column>
+In the preoperative suite, I marked the IMF and the breast footprint on her chest wall. We also discussed drains.\\
+Operative Report\\
+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.
+At the time that I was called into the OR, the mastectomies had been completed. I began with the first side - the mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery. I then irrigated the pocket with antibiotic saline. The pectoralis muscle was then elevated and divided at its inferomedial origin. The perforators were controlled with cautery and medium clips. I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine. Gloves were exchanged and the appropriate base diameter expander was placed into the pocket (deflated). The suture tabs were sutured to the chest wall with 3-0 PDS. 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 running 3-0 PDS. I then closed the interface between the pectoralis and Alloderm with a 3-0 PDS in a running fashion.
+Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline. One 15 blake was placed and sutured with a 3-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl pull-out suture.
+I then turned my attention to the contralateral breast. The mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery. I then irrigated the pocket with antibiotic saline. The pectoralis muscle was then elevated and divided at its inferomedial origin. The perforators were controlled with cautery and medium clips. I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine. Gloves were exchanged and an appropriate base diameter expender was placed into the pocket (deflated). The suture tabs were sutured to the chest wall with 3-0 PDS. 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 running 3-0 PDS. I then closed the interface between the pectoralis and Alloderm with a 3-0 PDS in a running fashion
+Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline. One 15 blake was placed and sutured with a 3-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl pull-out suture. Biopatches were placed on 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.
+Dr. Chong expects you to know: Nipple sparing vs skin sparing and reasoning (e.g. tumor close to nipple, ptotic breast), Base Width, History of radiation or plan for radiation, type of cancer\\
+Important Notes: Only Dr. Chong opens and handles the tissue expander. “Double” scrub (betadine, dry hands, avaguard) and double gloves. Will switch gloves before handling tissue expander. Dr. Chong does not fill the tissue expander intraoperatively.\\
+Placement order: If subpectoral, pectoralis muscle dissected, TE sutured in place before alloderm placed and sutured. If pre-pectoral, two pieces of alloderm sutured superiorly and inferiorly and then tissue expander placed before final closure of alloderm. The reasoning behind this is that Dr. Chong has switched to smooth expanders and they don't stay in place like textured implants and he treats them like DIP.\\
+Irrigation: 1L baci irrigation with cysto tubing\\
+Pre-operative markings: Bilateral IMF, meridian, also makes transverse markings at the level of the IMF but midline and lateral as to mark the level of the IMF incase it is obliterated during mastectomy portion, breast footprint.
+To place alloderm correctly, stuff in the piece under the pectoralis muscle and then pull it down. Usually will SPY case when sub-pectoral placement of TE.\\
+To fill tissue expander, first put it under water and suck out all of the air with filler needle with vac suction. Don't forget to make the fold in TE so it doesn't obstruct the filling port.\\
+Dr. Chong likes using high profile TE which have 3 bladders and preferentially fill the lower pole\\
+roll TE like a joint place the TE and then fit the alloderm in after it is set\\
+For dissection of lifting pectoralis major off chest wall, lift with browns and go in the fuzzies the pedicle is sitting in that fat, so once you’re over pect minor, get under the fat (the pectoral arterial branch is in that fat) and right on top of pect minor and blunt dissect up.\\
+Bovie25/25 to prevent the thermal injury\\
+Don't go too low or you will go into serratus. Don't start too high or you won't' be able to find pectoralis minor. You need GOOD RETRACTION with this method. The sliding plane is pectoralis minor underneath. Taking down pectoralis minor will make it bloody and Dr. Chong will think you are not following his directions and don't know what you are doing. There isn't a morbidity from taking down pectoralis minor.\\
+Dr. Chong tries to make this operation look perfect so he has little to do at the implant exchange and revision operations.\\
+Places TE central tab at breast meridian. (he uses a grid so breast surgeon doesn't wash away his breast IMF lines).
+</WRAP>
+<WRAP half column>
+{{:resident:img_4931.jpg?400|}}
+Tourniquet: No\\
+Drain: 15 blake drain placed over pectoralis/alloderm\\
+Sutures: 3-0, 4-0 monocryl closure, Alloderm 3-0 PDS, drain stitch 3-0 nylon\\
+Dressing: Dermabond, 1 inch steristrips cut over each tail of subcuticular, biopatch tegaderm, ABD pad, Bra\\
+</WRAP>
+</WRAP>
+==== Breast Fat Grafting ====
+<WRAP Group>
+<WRAP half column>
+I had a long discussion about the risks of the surgery including bleeding, pain, infection, contour deformity, injury to the skin, recurrence, wound healing problems, damage to surrounding tissue, and need for further surgery.  The patient understands that she will have to wear compression garments for the postoperative care, and I want her to ambulate daily.\\
+Operative Report\\
+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. \\
+Her donor sites were marked in preop  I infiltrated cc of wetting solution after making a small incision with a 11 blade.  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 as per closed Revolve system   I then placed the fat in sterile syringes for injection.  The incisions were closed with 4-0 chromic.\\
+I then made several stab incisions on the  breasts.  A total of XXX cc of fat graft was then infiltrated as per Coleman technique in the previously marked areas of deficit in the areas of her breast reconstruction.  The injection sites were closed with a 4-0 chromic.  She was placed into a binder and surgical bra after dressings were placed on the incisions.\\
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Suture: 4-0 chromic simple interrupted to close stab incisions for liposuction and fat grafting.\\
+Dressing: Bacitracin and band-aid over each site.\\
+</WRAP>
+</WRAP>
-At this time, I decided to hold off on any further bypasses.   The SPY did show areas of enlarged lymphatics, but this was the most prominent.  After recovery, if she requires further bypass, we can reimage her for future surgery.   I then closed the skin with 4-0 nylon and wrapped the hand and arm with a 3 inch ace bandage.
 ==== Nipple Reconstruction ====
+<WRAP Group>
+<WRAP half column>
 Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction.
@@ Line 496: / Line 696: @@
 I then made one stab incision on each breast - between the medial contour deformity and the lateral axillary deformity.  Then x cc of fat graft was then infiltrated as per Coleman technique in the previously marked areas of deficit in the superomedial and lateral areas of her breast recon of each breast (total cc).  The injection sites were closed with a 4-0 chromic suture.  Dermabond was applied to the incisions.  She was placed into a compressive garment after abd pads were placed on the incisions.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 4-0 chromics, 3-0, 4-0 monocryl\\
+Dressing: Dermabond, tegaderm\\
+</WRAP>
+</WRAP>
 ==== Oncoplastic Reconstruction ====
+<WRAP Group>
+<WRAP half column>
 Preop Dx:  History of lumpectomy, deformity of breast
 Procedure: oncoplastic reconstruction
@@ Line 520: / Line 737: @@
 The patient was placed into a sitting position to evaluate the reconstruction.  The staples and suture were removed and hemostasis confirmed.  The pattern was then stapled and a 3-point suture using 2-0 PDS was used at the T junction.  A x mm cookie cutter was then used to mark the position of the new NAC.  The IMF and vertical limbs were then closed with 3-0 monocryl followed by a 4-0 running monocryl.  The NAC was de-epitheliazed and the nipples delivered without tension.  The nipple was inset with 4-0 monocryl followed by a 5-0 monocryl. Steristrips were then applied to the NAC and to the IMF and vertical limbs.  The nipples were viable at the end of the procedure and the breasts soft.  She was placed into a surgical bra and transferred to recovery in stable condition.
-==== Panniculectomy ====
+</WRAP>
-Preop Dx:  Panniculitis, excess abdominal skin
+<WRAP half column>
-Procedure:  panniculectomy
-Anesthesia:  GETA
-Drains:  ???
-The risks included bleeding, pain, infections, damage to surrounding tissue, seroma, wound healing problems, need fur further surgery, loss of umbilicus, and unattractive scarring.  Informed consent was obtained.
+Tourniquet: No\\
+Drain: No\\
+Sutures: 3-point suture 2-0 PDS used at the T junction, 3-0 monocryl 4-0 running monocryl, 4-0 monocryl, 5-0 monocryl\\
+Dressing: Steristrips\\
-Operative Report
-The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
-I had marked the patient in the preoperative suite.  The lower incision was above the mons pubis and tapered laterally.  The incision was made with a 10 blade and then carried to the 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 below the umbilicus.  I then confirmed that we could close the wound with towel clamps and then made the superior skin incision.  The pannus was then removed after all the bleeding vessels were controlled and passed off to pathology.  The wound was irrigated and the hemostasis was confirmed.  I then closed the SFS layer with 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer.  The skin was then closed with 4-0 monocryl.  The skin was dressed with ???.   Prior to closure the patient had two 15 blake drains placed with exit sites laterally .
+</WRAP>
+</WRAP>
 ==== Bilateral Breast Reduction ====
+<WRAP group>
+<WRAP half column>
 Preop Dx:  Symptomatic macromastia
 Procedure:  Bilateral breast reduction
@@ Line 542: / Line 760: @@
 Complications:  None
 Findings:   Bilateral viable NAC
-Drains:  none
+Drains:  none - ??cut off for possible drain placement?
-symptomatic macromastia with shoulder, back, and neck pain which have been refractory to any conservative measures.
 We had a long discussion regarding the risks,benefits, and alternatives to breast reduction.  The risks included but were not limited to bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, need for further surgery, wound healing problems (especially T point junction), changes to nipple sensation, and nipple loss (need for free nipple graft),  I outlined the incisions and location of the final scars for the patient who understood.  We also discussed that I do not guarantee a specific size, but will reduce enough of the breast tissue to improve her symptoms and to preserve a feminine shape for her.  Informed consent was obtained.
@@ Line 558: / Line 774: @@
 The patient was placed into a sitting position and were symmetric.  A 42mm cookie cutter was then used to mark the position of the new NAC.  The IMF and vertical limbs were then closed with 3-0 monocryl followed by a 4-0 running monocryl.  The NAC was excised and the nipples delivered without tension.  The nipples were inset with 4-0 monocryl followed by a 5-0 monocryl.  Dermabond was then applied to the NAC and steri strips to the IMF and vertical limbs.  The nipples were viable at the end of the procedure and the breasts soft.  She was placed into a surgical bra and transferred to recovery in stable condition.
-NAC: de-epi and then make a cross. We do this incase we need to free nipple graft
+Markings: In order to make the breast triangle, he uses the breast meridian and pulls the breast from one side to the other marking the base of his triangle. This is a sort of pinch test to make sure the breast will close.\\
+Surgical Steps:\\
+. Mark NAC with 38 mm cookie cutter.\\
+. Use 15 blade around the NAC to start de-epi.\\
+. Breast tourniquet with lap pad (Roll and Twist) and Kocker.\\
+. Continue de-epi inferiorly as far as you can go.\\
+. Take down tourniquet and use Face Lift scissors to complete de-epi of central/inferior pedicle.\\
+. Next, focus on the making the pedicle. Start on the medial limb and make your incision and extend a little bit beyond the medial triangle/wing. **Do not undermine the pedicle.** Constantly use your hands to go back and forth to check. **Stop right before pectoralis fascia.**\\
+. Now focus on the lateral side. Your assistant puts his or her hand in the medial vertical limb and holds the breast while you make the lateral incision down just before pectoralis fascia.\\
+. Complete the superior incision to free your pedicle **without undermining the pedicle**.\\
+. Cut out your medial and lateral wings. Cut straight and don't get in the wrong plane. Don't double cut. Don't disrupt the IMF. //The trick is to HOLD the tissue but not HORK up the tissue. This avoids skiving and getting into pectoralis fascia.//
+. The new triangle where the NAC will be delivered is excised. This is the only part where he skives and digs in to thin out the area so the NAC will not look retracted.\\
+. All your tissue has been excised and now you can do the three point stitch with 0 PDS to set the meridian of the breast. Through the skin at the IMF (at merdidian), deep dermal buried through medial and lateral wings and back through IMF. Tie the knot on the skin.\\
+. Staple the breast. Closure: 3-0, 4-0 monocryl for horizontal portion. 3-0 ONLY for vertical portion. (ie no subcuticular for vertical portion for virgin BBR)\\
+.  Mark NAC with 38 mm cookie cutter. De-ep and do cross for bail out grafting backup option. Deliver the NAC by touching adjacent dermis and avoid handling NAC itself.\\
+. Staple at 12, 3, 6, 9 and then staples in between. Close with 4-0, 5-0 monocryl.\\
+. Dressing is 1 inch steri-strips except over three point stitch which gets a little bacitracin. ABDs/Bra.\\
+Dressing: Baci over Tri-stitch and steri-strips over the rest.\\
+Marking and Sizing the Nipple\\
+Sit patient up once all incisions are stapled closed. Mark nipple position at area of greatest projection. Lie the patient back flat. Chong DOES NOT remove the staples and remark the nipple. De-epithelialize the skin within the circle and then cruciate the dermis. Pull nipple through and secure with interrupted 4-0 monocryl and then running 5-0 monocryl. ***Chong does not run a 4-0 monocryl along the vertical limb of the wise pattern. He only closes this part with interrupted 3-0 sutures.
+NAC: de-epi and then make a cross. We do this incase we need to free nipple graft\\
+. What are indications for surgery? symptomatic macromastia with shoulder, back, and neck pain which have been refractory to any conservative measures.\\
+. Why does Dr. Chong prefer the WISE pattern?  It is a way of reducing or lifting the breast in the horizontal vector as well as the vertical vector and that is a very predictable pattern.\\
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 3-0 monocryl, 4-0 running monocryl, 4-0 monocryl, 5-0 monocryl, running 5-0 monocryl\\
+Dressing: Dermabond, Baci over tri-stitich, steristrips\\
+</WRAP>
+</WRAP>
 ==== Breast Revision ====
+<WRAP Group>
+<WRAP half column>
 Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction
 Procedure:  Revision breast reconstruction with fat grafting, revision of donor site (abdomen), and breast mastopexy - bilateral.
@@ Line 589: / Line 850: @@
 Fat Grafting -> ABX course
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 4.0 chromic sutures, 3-0 moncryl for the deep dermal layer and 4-0 monocryl for the superficial layer, 3-0 and 4-0 monocryl sutures\\
+Dressing:Steristrips, dermabond\\
+</WRAP>
+</WRAP>
+===== Aesthetics =====
+==== Blepharoplasty ====
+<WRAP Group>
+<WRAP half column>
+Preop Dx:  Bilateral upper lid dermatochalasis\\
+Procedure:  Bilateral upper lid blepharoplasty\\
+Anesthesia:  GETA\\
+Drains:  none\\
+In the preoperative suite, I marked the upper lid crease which was at least 8mm above the ciliary margin and did not extend the markings more medial than the punctum.  The amount of skin resected was then pinched and marked.  All markings were performed with the patient upright.  Moreover, there was greater than 1cm of skin between the upper line and the brow.
+Operative Report
+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.
+Corneal protectors with ophthalmic bacitracin were placed.  I then infiltrated both incisions with 1% lidocaine with epi - (3cc total for both lids).  I began with the right upper lid.  Using a fresh 15 blade the skin was incised and removed taking great care to preserve the orbicularis.  I then cauterized any bleeding with a Colorado tip bovie.  The wound was then irrigated and was hemostatic.  The wound was then closed with interrupted 6-0 prolene sutures.
+I then turned my attention to the contralateral lid.  Using a fresh 15 blade the skin was incised and removed taking great care to preserve the orbicularis.  I then cauterized any bleeding with a Colorado tip bovie.  The wound was then irrigated and was hemostatic.  The wound was then closed with interrupted 6-0 prolene sutures.
+The corneal protectors were removed and the eyes washed with HBSS.  The patient was then extuated without complications.   At the conclusion of the procedure, both eyes were easily closed without any scleral show.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 6-0 prolene sutures \\
+Dressing: No\\
+</WRAP>
+</WRAP>
+==== Panniculectomy ====
+<WRAP Group>
+<WRAP half column>
+Preop Dx:  Panniculitis, excess abdominal skin\\
+Procedure:  panniculectomy\\
+Anesthesia:  GETA\\
+Drains:  ???\\
+The risks included bleeding, pain, infections, damage to surrounding tissue, seroma, wound healing problems, need fur further surgery, loss of umbilicus, and unattractive scarring.  Informed consent was obtained.
+Operative Report
+The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
+I had marked the patient in the preoperative suite.  The lower incision was above the mons pubis and tapered laterally.  The incision was made with a 10 blade and then carried to the 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 below the umbilicus.  I then confirmed that we could close the wound with towel clamps and then made the superior skin incision.  The pannus was then removed after all the bleeding vessels were controlled and passed off to pathology.  The wound was irrigated and the hemostasis was confirmed.  I then closed the SFS layer with 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer.  The skin was then closed with 4-0 monocryl.  The skin was dressed with ???.   Prior to closure the patient had two 15 blake drains placed with exit sites laterally .
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer, 4-0 monocryl\\
+Dressing: ???\\
+</WRAP>
+</WRAP>
+==== Abdominoplasty ====
+<WRAP Group>
+<WRAP half column>
+Pre-op: Mark the position of the lower incision and the scar\\
+Position: Supine\\
+Prep: "Tuck and roll"\\
+Antibiotics: Yes, indicated. Ancef. If penicillin allergy, vancomycin.\\
+Steps: Lower abdominal incision was made with a fresh 10 blade. The dissection was carried down to the fascia with bovie electrocautery.  The SIEV and SIEA branches were all controlled with cautery and surgical clips.  The abdominal flaps were then elevated to the level of the umbilicus.  The umbilicus was then incised with a 11 blade and the stalk dissected to the abdominal wall.   At this point we continued our elevation to the xiphoid process.  Intercostal and rectus perforators were controlled with cautery and surgical clips.
+I then identified the area of diastasis.  This was marked and the diastasis was corrected with 0 Nurolon sutures in an interrupted figure of 8 fashion.  The wound was then irrigated and hemostasis was confirmed.  The patient was then placed into a flexed position and the upper abdominal flap was advanced to the lower to determine the skin resection.  This was marked and the skin was excised with a 10 blade and bovie cautery.  The incision was temporarily closed with staples using our vertical plum lines made in preop as reference points.  The site for the umbilicus was identified and marked.  I then defatted the area of the umbilicus.
+I then placed 2 blake drains (15) with exit points at the lateral incision.  The wound was irrigated and hemostasis confirmed.  I then closed the SFS with 2-0 vicryl in an interrupted fashion.  The skin was then closed with 3-0 and then 4-0 monocryl suture.  Steristrips were applied and the drains were secured.  I then cut out the position of the umbilicus with a 15 blade and delivered it through the abdominal wall.  It was inset with 4-0 monocryl deep dermal sutures and dermabond. The patient was then placed into a surgical binder and extubated without difficulty.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 2-0 vicryl in an interrupted fashion, 3-0 and 4.0 monocryl suture, 4-0 monocryl deep dermal sutures\\
+Dressing: Dermabond\\
+</WRAP>
+</WRAP>
+===== Other Microsurgery =====
+==== PT Dissection ====
+<WRAP Group>
+<WRAP half column>
+The medial malleolus was marked and an incision was made just posterior to this and connecting to the wound. Prior to this the tourniquet was insufflated to 250mmHg pressure. Dissection was carried down to the fascia and the fascia was divided with electrocautery. The interval between the superficial and deep posterior compartments was developed. The fascia overlying the PTA in the deep posterior was opened sharply. Dessection was then carried circumferentially around the PTA and veins. Great care was taken to identify the PT nerve and preserve it. Once the PTA and veins were prepared, we then brought the ??? flap into the wound.
+</WRAP>
+<WRAP half column>
+</WRAP>
+</WRAP>
+==== STA Dissection ====
+<WRAP>
+<WRAP half column>
+The STA was chosen based on the donor site location and prior scars.  I infiltrated the pretragal region and scalp with sterile saline to facilitate hydrodissection.  A 15 blade was used to make the scalp incision which was made in continuity with the defect.  Scalp flaps were raised.   The distal superficial temporal artery and vein (STA and STV) were identified and dissected circumferentially.  The dissection was carried down to the pretragal region until we had vessels that were suitable in diameter for microsurgical reconstruction.
+</WRAP>
+<WRAP half column>
+{{:resident:screen_shot_2020-04-13_at_4.11.50_pm.png?400|}}
+{{:resident:screen_shot_2020-04-13_at_4.18.29_pm.png?400|}}
+{{:resident:screen_shot_2020-04-13_at_4.52.26_pm.png?400|}}
+</WRAP>
+</WRAP>
+==== Facial Artery Dissection ====
+<WRAP>
+<WRAP Half Column>
+An incision was placed 1.5 cm caudal the the inferior mandibular border along a skin crease.  This was centered over the anterior edge of the masseter and at the palpable site of the facial artery.  Lidocaine with epi 1% was infiltrated into the wound.  A 15 blade was used to make the skin incision and the platysma was divided with electrocautery.
+The superficial cervical fascia was divided sharply and the facial vein was identified.  This was dissected proximally and a second large branch was identified.  They were dissected circumferentially and controlled with vessel loops.  Superficial lymph nodes were then removed to facilitate identification and dissection of the facial artery.   This was dissected circumferentially and controlled with vessel loops.  A lidocaine soaked neuropattie was placed on the vessels until the microvascular anastomosis. The marginal mandibular nerve was identified during the dissection and preserved.
+</WRAP>
+<WRAP half column>
+{{:resident:screen_shot_2020-04-13_at_4.52.58_pm.png?400|}}
+Technique:\\
+Incision: 1 finger breadth inferior to mandible anterior to masseter\\
+Divide platysma\\
+Deep fascia (bluntly)\\
+Node of Star - submandibular lymph node which lies superficial to facial artery at the masseter\\
+Marginal mandibular nerve will be superior to the incision\\
+</WRAP>
+</WRAP>
+==== Gracilis Muscle Flap to Perineum ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+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 time that I was called into the room the anus had been removed and a small dead space existed. The wound was reassessed and hemostasis obtained with cautery and surgical clips. I then turned my attention to the harvest of the gracilis muscle.
+A curvilinear incision was made just posterior to the axis of the adductor longus muscle. This was carried down to the muscle fascia and great care was taken to preserve the GSV. The fascia was then opened and the gracilis muscle was identified. This was taken to the insertion and divided with cautery. The branches from the SFA were controlled with surgical clips and divided. The flap was then raised from proximal to distal. I then identified the skin perforator and this was divided. The pedicle was seen just deep to this and the dissection was stopped. I then made a tunnel to the perineum in the subcutaneous plane. Tunnel is appoximately 3 chong fingers in width. He also divides the SFS to prevent bands that would compress the pedicle.
+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 gracilis was then passed into the perineum and inset into the perineal dead space. It was inset circumferentially with 3-0 pds sutures. The superficial fascia and muscle were then reapproximated with a 3-0 pds. The skin was then closed with 3-0 pds in an interrupted fashion. A 10 blake drain was placed into the perineum.
+The donor leg was then irrigated and hemostasis confirmed. A 15 blake drain was placed and the deep dermal layer was closed with 3-0 monocryl. The skin was then reapproximated with 4-0 monocryl. The wound was dressed with dermabond.
+Procedure: gracilis muscle flap to perineum, SPY indocyanine green fluorescence angiography\\
+Markings: Frog leg patient. Adductor longus should be bowed out muscle and mark entire course to knee. Mark gracilis 2 finger breadths below\\
+The patient is to be transferred with the Right leg ADDUcted at all times and a dry abd pad on the perineum and sacrum at all times (changed qid).\\
+</WRAP>
+<WRAP half column>
+{{:resident:whatsapp_image_2020-05-10_at_5.32.20_pm.jpeg?400|}}
+Tourniquet: No\\
+Drains: 15 blake in thigh and 10 blake in the perineum\\
+Sutures: Thigh: 3-0 monocryl, 4-0 monocryl, Perineum 3-0 PDS to parachute in muscle, 3-0 vicryl to close perineum (because it is less prickly than PDS)\\
+Dressings: Dermabond or steristrips depending on if Dr. Chong wants to hide scar for thigh. Tegaderm biopatch for drains, ace wrap for thigh, but don't go too high to compress tunnel. Bacitracin and ABD for perineum\\
+Restrictions: POD#0 bedrest. ABduction pillow while in bed. POD#1 okay to mobilize with PT/OT. Should walk with legs shoulder width apart. No ABduction of surgical extremity.\\
+Questions you will be asked:\\
+. What superficial vein may you encounter during dissection? Greater saphenous vein\\
+. What is the blood supply to the gracilis muscle? It is a type II muscle flap. Dominant pedicle is branch of medial femoral circumflex artery. It cannot survive off SFA perforators. Pedicle AND skin perforator approximately 10 cm from pubic symphsis.\\
+. Describe course of medial femoral circumflex artery? Between adductor magnus and longus.\\
+. What nerve supplies the gracilis muscle? anterior branch of obturator.\\
+. What is the Origin of the gracilis muscle? The pubic symphysis and the inferior pubic ramus.\\
+. What is the Insertion of the gracilis muscle? Medial surface of the tibia via the Pes Anserinus "goose foot".\\
+. What other muscles insert at the pes anserinus? sartorius, gracilis, semitendinosus.\\
+</WRAP>
+</WRAP>
+==== Gracilis Free Flap ====
+<WRAP Group>
+<WRAP half column>
+Procedure:  Perineal reconstruction with gracilis flap
+SPY indocyanine green fluorescence angiography
+Surgeons:  Tae Chong, MD
+Anesthesia:  GETA
+Findings:   Well vascularized gracilis flap, obliteration of the dead space
+Drains:  15 blake drain in each thigh
+Benefits: Vascularized muscle in promoting wound healing, especially in irradiated fields.
+I had a long discussion with the patient about the goals of reconstruction.  The purpose of utilizing a flap is to bring in well vascularized tissue to promote wound healing.  The risk of the gracilis flap as with any reconstruction includes bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, need for drain, donor site numbness, wound healing problems, loss of flap, and need for further surgery.
+Informed consent was obtained.
+Operative Report
+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 SIDE 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>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 3-0 monocryl deep dermals followed by a 4-0 monocryl subcuticular suture\\
+Dressing: Dermabond, ace bandage\\
+</WRAP>
+</WRAP>
+==== Gastrocnemius Muscle Flap ====
+<WRAP Group>
+<WRAP half column>
+Preop Dx:  Composite wound of the proximal tibia with exposed bone
+Procedure:  Preparation of wound bed x cm, gastrocnemius muscle flap, split thickness skin graft x cm
+SPY indocyanine green fluorescence angiography
+Anesthesia:  GETA
+Findings:   Viable medial gastrocnemius flap
+Drains:  Blake drain
+We had a long discussion regarding the use of gastrocnemius flap transfer for reconstruction.  The risks include bleeding, pain, infection, wound healing problems, damage to surrounding tissue, disability, scarrring, asymmetry, need for further surgery, and partial/ total flap loss.  This occurs in a small percentage of patients, but if caught early can be salvaged with an emergent operation.  We outlined the approach for the flap harvest and for the flap inset.
+Operative Report
+The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
+I began with debridement of the bony edge and soft tissue to healthy tissue.  The unstable skin and scar were excised with a fresh 15 blade down to bone and fascia to bleeding tissue.  I then irrigated the wound with 3 liters of antibiotic saline.  The appliance was visible in the distal wound but also in the proximal tibia.  Once this was accomplished, I obtained hemostasis.  The leg was then elevated and the tourniquet was insufflated.
+I made an oblique incision from the caudal end of the wound to the posterior calf near the midline.  Dissection was carried down to the fascia with electrocautery.  The GSV was identified and controlled with clips then divided.  The crural fascia was divided and the gastrocnemius was identified.  I then developed the plane between the gastroc and soleus muscle, preserving the plantaris with the soleus.  The midline of the gastrocnemius was identified and the lesser saphenous vein was identified and preserved with the remaining lateral gastronemius.  The medial gastrocnemius was then divided from the achilles tendon and elevated distal to proximal.  The muscle fascia was then scored longitudinally to increase the width of the flap.  It was easily inset into the wound covering all exposed appliance and tibia.   The tourniquet was then taken down.
+The flap was then inset with 3-0 pds suture in an interrupted fashion.  A 15 blake drain was placed into the wound and secured with a 2-0 nylon.  The donor site was then closed with 3-0 monocryl followed by 4-0 nylon suture.  I then obtained a ???  cm split thickness skin graft from the right thigh at 12 one thousandth of an inch.  The donor site was dressed with a bio occlusive dressing.  The graft was meshed 1:1.5 and sutured in place with 4-0 chromic.  The wound was then dressed with bacitracin and adaptic.   At the conclusion of the operation, the flap was pink, warm and viable with bleeding from all the edges.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 3.0 pds suture, 2-0 mylon, 4-0 nylon suture, 4-0 chromic\\
+Dressing: bio occlusive, bacitracin and adaptic\\
+</WRAP>
+</WRAP>
+==== Lymphatico venous bypass ====
+<WRAP Group>
+<WRAP half column>
+Preop Dx:  Lymphedema of the  arm
+Procedure:  SPY indocyanine imaging of lymphatic vessels
+Lymphatico venous anastomosis x - 22 modifier, complex due to size of vessels (<1mm) and complex anatomy
+Anesthesia:  GETA
+Findings:   Lymphatic congestion in forearm, prominent lympatic in the middle third of the forearm, patent lymphaticovenous bypass x
+Drains:  none
+She understands that lymphaticovenous bypass is not a cure, but a treatment adjunct.  She will need to continue to use compression and wraps.   However, she should begin to see symptomatic improvement with better tolerance of the wraps and in some cases will be able to use the sleeves intermittently and not all the time.
+The procedure involves decompressing the lympatics into the veins using supermicrosurgery to vessels that are 0.5mm or less.  The surgery is complex, but is performed just under the skin and is performed outpatient.
+The risks include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, need for multiple procedures, scarring, wound healing problems, worsening of lymphedema, and failure of the bypass.
+Operative Report
+The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.
+I injected 0.1ml of ICG into each webspace and in the wrist and forearm.  SPY technology was used to image the lymphatics.  The hand and distal wrist demonstrated xxx.  In her forearm, there were several areas of congested lymphatics with a marked reticular pattern.  I marked the most prominent lymphatic vessel on the dorsal forearm in the middle third.  I then injected isosulfan blue in the dermal layer just distal to the proposed incision.
+I then wrapped the arm loosely with an esmarch and gently exsanguinated the arm.  A tourniquet was placed to 250mmhg pressure.  An incision was made with a 15 blade.  Dissection was carried through the dermis to the immmediate subdermal layer.  There was a significant amount of fluid and lymphatic congestion.  After exhaustive dissection, a prominent lymphatic vessel was identified with blue dye staining.  This was dissected circumferentially.
+I then made a small venotomy after placeing microvascular clamps.  The distal end of the lymphatic vessel was then sutured to the vein in an end to ??? manner.  This was performed with 11-0 nylon under maximal zoom under the operating microscope.  After the anastomosis was complete the clamps were removed and the tourniquet was taken down.  There was egress of the isosulfan blue into the vein from the lymphatic vessel.  I then waited 20 minutes to begin the next tourniquet run.
+The arm was placed under tourniquet control and another end to side anastomosis was performed to the proximal end of the lymphatic vessel.  This was done with 11-0 nylon in an interrupted fashion.  Of note, dye and lymphatic fluid were present within the vein from the other L-V bypass, confirming the on table patency of the first anastomosis.
+After this was done the wound was irrigated and hemostasis was obtained.
+At this time, I decided to hold off on any further bypasses.   The SPY did show areas of enlarged lymphatics, but this was the most prominent.  After recovery, if she requires further bypass, we can reimage her for future surgery.   I then closed the skin with 4-0 nylon and wrapped the hand and arm with a 3 inch ace bandage.
+</WRAP>
+<WRAP half column>
+Tourniquet:  arm\\
+Drain: No\\
+Sutures: 11-0 nylon, 4-0 nylon\\
+Dressing: No\\
+</WRAP>
+</WRAP>
 ==== Soleus Muscle Flap ====
+<WRAP Group>
+<WRAP half column>
 Preop Dx:  Composite wound of the ? middle tibia with unstable scar and underlying osteomyelitis
@@ Line 612: / Line 1226: @@
 The flap was then inset with 3-0 pds suture in an interrupted fashion.  A 10 blake drain was placed into the wound and secured with a 2-0 nylon.  The donor site was then closed with staples.  I then obtained a ?  cm split thickness skin graft from the right thigh at 14 one thousandth of an inch.  The donor site was dressed with a bio occlusive dressing.  The graft was meshed 1:1.5 and sutured in place with 4-0 chromic.  The wound was then dressed with bacitracin and adaptic.   I then applied a durable wound vac placed at 50mmHg pressure.  I put the patient into a posterior splint.  At the conclusion of the operation, the flap was pink, warm and viable with bleeding from all the edges.
-==== Split Thickness Skin Graft ====
+</WRAP>
+<WRAP half column>
-Procedure:  Preparation of wound bed ? cm2
+Tourniquet: Leg\\
-Split thickness skin graft to back? cm2
+Drain: 10 blake\\
-? wound vacuum placement ?cm2
+Sutures: 3-0 pds, 2-0 nylon, 4-0 chromic\\
-Anesthesia:  GETA
+Dressing: bio occlusive, bacitracin and adaptic\\
-Findings:   Clean granulation tissue bed
-Drains:  Wound vac
-   At the time of surgery the patient had a clean wound  and was prepared for a skin graft vs local flap.
-I discussed with the patient the risks of split thickness skin graft which include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, loss of skin graft and need for further surgery.  Informed consent was obtained.
+</WRAP>
+</WRAP>
-Operative Report
-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 operation began with preparation of the wound bed.  The skin edges were debrided with a fresh 15 blade down to the level of the wound.  The wound was then debrided of excess granulation, retained vac sponge, and debris with a 10 blade and with 2 liters of antibiotic irrigation delivered with pulse lavage.  I then measured the wound and it was ? cm2.
-This was then transferred to his left thigh and a dermatome set at ? one thousandth of an inch thickness was used to obtain a STSG.  The skin graft was then meshed at 1:?.  It was placed on the wound bed and secured with 4-0 chromic sutures.  Adaptic, bacitracin, and a ??wound vacuum were then placed at 125mmHg.   The donor site was managed temporarily with a moist dressing and then dressed with a large tegaderm.
-==== STA Dissection ====
-The STA was chosen based on the donor site location and prior scars.  I infiltrated the pretragal region and scalp with sterile saline to facilitate hydrodissection.  A 15 blade was used to make the scalp incision which was made in continuity with the defect.  Scalp flaps were raised.   The distal superficial temporal artery and vein (STA and STV) were identified and dissected circumferentially.  The dissection was carried down to the pretragal region until we had vessels that were suitable in diameter for microsurgical reconstruction.
 ==== Bilateral pectoralis Muscle Flaps ====
+<WRAP Group>
+<WRAP half column>
 Preop Dx:  Sternal wound infection
@@ Line 675: / Line 1282: @@
 Strict sternal precuations
 No heavy lifting"
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 0 PDS sutures in figure of 8 fashion, 2-0 nylon, 3-0 monocryl suture for the deep dermal layer and then 3-0 nylon for the skin\\
+Dressing: No\\
+</WRAP>
+</WRAP>
 ==== Reverse Sural Flap ====
+<WRAP Group>
+<WRAP half column>
 Preop Dx:  Composite wound of the ???with exposed hardware and with unstable scar.
 Procedure:  Debridement of wound (skin, fascia ???), preparation of wound bed ???, reverse sural flap, split thickness skin graft ??? cm incisional wound vacuum >50cm2.
@@ Line 703: / Line 1327: @@
 The flap was then inset with 3-0 pds suture in an interrupted fashion.  Great care was taken to ensure no pressure or acute twist to the pedicle.  The donor site was then closed with 3-0 PDS but required a small skin graft.  I then obtained a 6x11cm cm split thickness skin graft from the right thigh at 14 one thousandth of an inch.  The donor site was dressed with a bio occlusive dressing.  The graft was pie crusted and sutured in place with 4-0 chromic.  The wound was then dressed with bacitracin and adaptic.   I then applied an incisional Prevena  wound vac placed at 50mmHg pressure.  I put the patient into a soft splint with the heel and calf padded to allow the pedicle of the flap to float.  At the conclusion of the operation, the flap was pink, warm and viable with bleeding from all the edges.  The flap was dressed with bacitracin.
-==== Tissue Expander ====
+</WRAP>
-Dr. Chong expects you to know: Nipple sparing vs skin sparing and reasoning (e.g. tumor close to nipple, ptotic breast), Base Width, History of radiation or plan for radiation, type of cancer
+<WRAP half column>
-Important Notes: Only Dr. Chong opens and handles the tissue expander. "Double" scrub (betadine, dry hands, avaguard) and double gloves. Dr. Chong does not fill the tissue expander intraoperatively.
+Tourniquet: Leg\\
+Drain: No\\
+Sutures: 3-0 pds suture,4-0 chromic\\
+Dressing: Bio occlusive, bacitracin and adaptic\\
-Placement order: If subpectoral, pectoralis muscle dissected, TE sutured in place before alloderm placed and sutured. If pre-pectoral, two pieces of alloderm sutured superiorly and inferiorly and then tissue expander placed before final closure of alloderm.
-Sutures: 3-0, 4-0 monocryl closure, Alloderm 3-0 PDS
-Irrigation: 1L baci irrigation with cysto tubing
-Drain: 15 blake drain placed over pectoralis/alloderm
-Dressing: Dermabond, 1 inch steristrips cut over each tail of subcuticular, biopatch tegaderm, ABD pad, Bra
-Pre-operative markings: Bilateral IMF, meridian, also makes transverse markings at the level of the IMF but midline and lateral as to mark the level of the IMF incase it is obliterated during mastectomy portion, breast footprint.
+</WRAP>
+</WRAP>
-In the preoperative suite, I marked the IMF and the breast footprint on her chest wall.  We also discussed drains.
-Operative Report
-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 Dr. ???' s op note for full details of the mastectomy.
-At the time that I was called into the OR, the mastecomies had been completed.  I began with the {LEFT/RIGHT/SIDE:304012941} 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.  I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine.  Gloves were exchanged and a ??? expander with a ???cm BD was placed into the pocket (deflated).  The suture tabs were sutured to the chest wall with 3-0 PDS.   A sheet of???  size??? 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 running 3-0 PDS.  I then closed the interface between the pectoralis and Alloderm with a 3-0 PDS in a running fashion.
+==== Vertical Rectus Abdominis Muscle Flap ====
-Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline.  One15 blake was placed and sutured with a 3-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl pull-out suture.
+<WRAP Group>
+<WRAP half column>
-I then turned my attention to the contralateral breast.   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.  I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine.  Gloves were exchanged and a ??? expander with a???cm BD was placed into the pocket (deflated).  The suture tabs were sutured to the chest wall with 3-0 PDS.   A sheet of ????  size ? 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 running 3-0 PDS.  I then closed the interface between the pectoralis and Alloderm with a 3-0 PDS in a running fashion
+Preop Dx: Large perineal wound after resection of ???
+Procedure: Vertical rectus abdominis flap
+SPY fluorescence angiography
+EBL: ???cc plastic surgery portion
+Findings: Large pelvic exenteration defect, viable VRAM
+Drains: Perineal 15 blake
-Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline.  One 15 blake was placed and sutured with a 3-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl pull-out suture.  Biopatches were placed on 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.
+history of ??? who presents for reconstruction after pelvic exenteration.
+I had a long discussion with the patient about the goals of reconstruction. The purpose of utilizing a flap is to bring in well vascularized tissue to promote wound healing. The most appropriate based on the size of the defect and the need to obliterate the pelvis is the vertical rectus abdominis flap. He would also require advancement of local tissue to reduce the extent of the lateral component. The risk of these flaps as with any reconstruction include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, need for drain, donor site numbness, wound healing problems, loss of flap, and need for further surgery.
-==== Tissue Expander Exchange for Implants ====
+Operative Report
-Preop Dx:  ??? breast mastectomy, history of ?
+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.
-Procedure:  ??? breast TE exchange,
-Surgeons:  Tae Chong, MD
-Anesthesia:  GETA
-Complications:  none
-Findings:   Well healed expander pocket
-Drains:  None
-Implants: R ???
-L ????
- history of ??? breast mastectomy reconstructed with TE and ADM.   She was seen in clinic and after adequate expansion she was found to be a good candidate for exchange.  We discussed her desire to be as symmetric as possible with the contralateral breast and a natural silhouette
+At the time that I was called into the OR, the defect was extensive and had a large pelvic volume requirement.The defect was reassessed and a ??? cm skin island was needed.
-I also had a discussion with her about the need for capsulotomies for lower pole expansion and to utilize superomedial capsulotomies for the chest wall to breast recon transition.
+I then began the flap elevation of the ??? VRAM. The pedicle was dopplered and found to be intact. A ??? cm wide VRAM was designed around the periumbilical perforators. The skin was incised and beveled out. The flap was then elevated to the most lateral lateral row perforator to preserve as much fascia as possible for abdominal closure. The flap was then elevated from distal to proximal. The DSEA was divided and controlled with medium clips. The pedicle was protected in its entirety.
-We discussed the risks of TE exchange which can include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, need for further surgery, capsular contracture, and loss of implant.
+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.
-Operative Report
+The proximal portion of the skin was de-epithelialized and the flap was passed into the pelvis. The flap passed easily into the perineum with the muscle obliterating the floor of the pelvis. The muscle was inset with 3-0 pds and a 15 blake placed to drain the superficial perineal space. The skin was then inset with 3-0 pds for the deep dermal layer followed by 3-0 pds for the skin.
-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.
+</WRAP>
+<WRAP half column>
-In the preoperative suite I marked the IMF on both sides and the location of the capsulotomies. I began with the ???breast. The prior mastectomy scar was incised and the dissection taken to the capsule with bovie cautery. The capsule was divided and the expander was deflated. I then removed the expander.  I then placed several implant sizers, and the closest was the ??? implant ???? cc.  The lateral breast contour was confirmed with palpation. The capsule was temporarily closed and the skin stapled.
-I then turned my attention to the contralateral breast. The prior mastectomy scar was incised and the dissection taken to the capsule with bovie cautery. The capsule was divided and the expander was deflated. I then removed the expander. I then placed several implant sizers, and the closest was the ??? implant ??? cc.   The lateral breast contour was confirmed with palpation. The capsule was temporarily closed and the skin stapled. She was placed into a sitting position to confirm size, shape, and symmetry. The implants were removed.
-I then irrigated the pocket copiously with antibiotic irrigation. We exchanged gloves and the skin was reprepped. The implants were then placed into the pocket confirming the orientation. I then closed the capsule with 3-0 PDS in an interrupted fashion. The skin was closed with 3-0 monocryl and then with a running pullout 4-0 monocryl.
-Dermabond was applied and the patient was placed into a surgical bra. The patient was extubated and transferred to recovery in stable condition.
-==== Top Surgery ====
-Preop Dx:  Gender affirmation surgery, top surgery candidate
-Procedure:  Bilateral subcutaneous mastectomy and free nipple graft
-Prevena incisional wound vacuum placement bilaterally (13cm sponge)
-Findings:   Breast tissue removed, hemostatic wound bed, healthy dermal bed for graft
-Drains:  15 blake drain x2
-female with a history of gender identity disorder who has received counseling and medical approval to initiate gender affirmation surgery.  She met all the WPATH guidelines.
-The risks of surgery include but are not limited to bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, disability, wound healing problems, loss of free nipple graft, complete loss of sensation of the nipple, contour problems and need for further intervention.
-Operative Report
-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.   In the preoperative suite the IMF was marked and tapered superolaterally to contour with the lateral pectoral border.  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 left breast tissue.  The superior incision was confirmed by tailor tacking.   I then used a 20cc syringe plunger as a template for the new NAC (2.5cm in diameter).  The nipple was excised full thickness and the breast tissue and excess soft tissue was removed - the nipple graft was placed in a moist lap pad.  I then made the superior incision.  The superior flap was raised to the chest wall at 1cm of thickness.   The breast tissue was completed, the lower incision was made and the breast tissue and skin were passed off to ps then taken off the pectoralis fascia and the dissection carried down past the IMF, obliterating the IMF.     The wound was irrigated and bleeding controlled using cautery and surgical clips.  A 15 blake drain was placed.  The mastectomy flap was then advanced to the lower marking and closed with 3-0 and then 4-0 monocryl sutures.
-I then turned my attention to the contralateral breast.  The superior incision was confirmed by tailor tacking.   I then used a 20cc syringe plunger as a template for the new NAC (2.5cm in diameter).  The nipple was excised full thickness and the breast tissue and excess soft tissue was removed.  The nipple graft was placed in a moist lap pad.I then made the superior incision.  The superior flap was raised to the chest wall at 1cm of thickness.   The breast tissue was then taken off the pectoralis fascia and the dissection carried down past the IMF, obliterating the IMF.  Once this was completed, the lower incision was made and the breast tissue and skin were passed off to pathology.   The wound was irrigated and bleeding controlled using cautery and surgical clips.  A 15 blake drain was placed.  The mastectomy flap was then advanced to the lower marking and closed with 3-0 and then 4-0 monocryl sutures.
-I then placed the patient in the upright position.  The new nipple location was placed at the lateral pectoral border at the 4th intercostal space.  Symmetry was confirmed.  The template was used to de-epithelialize the nipple graft bed.  This was well vascularized and the nipple grafts were sutured with 4-0 chromic suture in an interrupted fashion.  Of note, the grafts were pie crusted to facilitate drainage of the graft bed.  Once this was done, steristrips were placed over the breast incision and the nipple grafts were secured with the small (13cm) Prevena incisional wound vac.  An excellent seal was obtained bilaterally.  The drains were secured with a 3-0 nylon and dressed with bio patch and tegaderm.
-==== Unilateral DIEP ====
+Tourniquet: No\\
+Drain: 15 blake\\
+Sutures: 3-0 pds\\
+Dressing: No\\
-Preop Dx:  ??? breast cancer
-Procedure: ??? breast recon with DIEP flaps
-Anesthesia: GETA
-Drains: 2 drains in the donor site and one drain in each breast
-Inset affected by implantable doppler:  ???
-female with a history of breast cancer who presents for ??? mastectomy and reconstruction.
+</WRAP>
+</WRAP>
-I had a long discussion with her about free tissue transfer for breast reconstruction using abdominal based flaps. The blood supply for the skin and soft tissue is derived from perforators through the rectus abdominis muscle. I will preserve the muscle and limit disability with the perforator dissection. This will have minimal to no functional significance. I outlined the location of the abdominal scars and umbilical scar.
-We discussed the need for 24-48 hours of ICU monitoring and the risk of flap loss due to microvascular complications. This occurs 3-5% of the time but if identified early can be salvaged. We also discussed the need to remove costal cartilage for IMA exposure.
-She understands that this is a complex operation but that it offers the best opportunity for a natural ptotic result. We also discussed secondary operations like fat grafting and nipple reconstruction.
-Operative Report
+==== Split Thickness Skin 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.
-Please refer to Dr ???'s note for full details of the mastectomy.Dr Mathes was the co-surgeon for this bilateral free flap due to the complexity and difficulty in DIEP dissection, history of ???, BMI in excess of ???, need for advanced microsurgical expertise and the bilateral nature of the operation.  This operation qualifies for the S code due to the above reasons.
+<WRAP Group>
+<WRAP half column>
-We utilized a two team approach. Dr. Mathes exposed the mammary vessels.
-Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the pectoralis - ???.    We then identified the 3rd rib costal cartilage and the pectoralis muscle was split longitudinally to access it.  The perichondrium was scored and elevated circumferentially.  The entire costal cartilage was removed.  We then split the posterior perichondrium and elevated it off the IM vessels.  The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace.  We then proceeded to dissect out the IMV.  Dissection was carried to the cephalad rib.  The artery was at least ??? mm and the vein was ??? mm.
+Procedure:  Preparation of wound bed ? cm2
+Split thickness skin graft to back? cm2
+? wound vacuum placement ?cm2
+Anesthesia:  GETA
+Findings:   Clean granulation tissue bed
+Drains:  Wound vac
-During this time we began the flap elevation portion of the operation by making the superior incision.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for 6cm. The flap dissection was then carried down to the rectus fascia.
+At the time of surgery the patient had a clean wound  and was prepared for a skin graft vs local flap.
-We then elevated the flap from lateral to medial starting on the ??? . The lateral row had ??? perforators.  An oval incision was made around the umbilicus and carried down to the fascia. We then began the dissection on the from medial to lateral. There were ??? medial row perforators that were identified. We decided to base the flap off the ??? row due to the size and quality.  This would be a hemi- flap using the ??? 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.
+I discussed with the patient the risks of split thickness skin graft which include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, loss of skin graft and need for further surgery.  Informed consent was obtained.
-We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  This added an additional 2 hours to each side.  The ??? row perforators were then clipped and divided and the remainder of the dissection was then performed.
+Operative Report
+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 brought the flap to the contralateral chest and secured it to the chest wall. The IMA vessels and DIEP pedicle vessels were then prepared under the microscope.  We then used a ??? mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis. The flap was well perfused with a doppler signal in the pedicle and on the skin.  The flap was then inset after we had de-epithelialized the portion of the buried flap.  A 15 blake drain was then placed and the flap inset with 3-0 and then 4-0 moncryl sutures.
+The operation began with preparation of the wound bed.  The skin edges were debrided with a fresh 15 blade down to the level of the wound.  The wound was then debrided of excess granulation, retained vac sponge, and debris with a 10 blade and with 2 liters of antibiotic irrigation delivered with pulse lavage.  I then measured the wound and it was ? cm2.
-The rectus fascia defect was then closed with buried 0 prolene in an interrupted figure of eight fashion. Two 15 blake drains were then placed. All drains were secured with 3-0 nylons and a biopatch. The SFS was then closed with 2-0 vicryl followed by a 3-0 monocryl for the deep dermal layer. The skin was closed with 4-0 running subcuticular suture. The umbilicus was then incised on the abdominal wall the the umbilical stalk delivered. The umbilicus was then inset with 4-0 monocryl deep dermal sutures. The skin was then dressed with dermabond and the patient was placed into an abdominal binder.
+This was then transferred to his left thigh and a dermatome set at ? one thousandth of an inch thickness was used to obtain a STSG.  The skin graft was then meshed at 1:?.  It was placed on the wound bed and secured with 4-0 chromic sutures.  Adaptic, bacitracin, and a ??wound vacuum were then placed at 125mmHg.   The donor site was managed temporarily with a moist dressing and then dressed with a large tegaderm.
-At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.
+</WRAP>
+<WRAP half column>
+Tourniquet: No\\
+Drain: No\\
+Sutures: 4-0 chromic sutures\\
+Dressing: Tegaderm, Adaptic, bacitracin\\
-==== Vertical Rectus Abdominis Muscle Flap ====
-Preop Dx: Large perineal wound after resection of ???
+</WRAP>
-Procedure: Vertical rectus abdominis flap
+</WRAP>
-SPY fluorescence angiography
-EBL: ???cc plastic surgery portion
-Findings: Large pelvic exenteration defect, viable VRAM
-Drains: Perineal 15 blake
-history of ??? who presents for reconstruction after pelvic exenteration.
-I had a long discussion with the patient about the goals of reconstruction. The purpose of utilizing a flap is to bring in well vascularized tissue to promote wound healing. The most appropriate based on the size of the defect and the need to obliterate the pelvis is the vertical rectus abdominis flap. He would also require advancement of local tissue to reduce the extent of the lateral component. The risk of these flaps as with any reconstruction include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, need for drain, donor site numbness, wound healing problems, loss of flap, and need for further surgery.
+==== Full Thickness Skin Graft ====
-Operative Report
+<WRAP Group>
-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.
+<WRAP half column>
-At the time that I was called into the OR, the defect was extensive and had a large pelvic volume requirement.The defect was reassessed and a ??? cm skin island was needed.
+I discussed with him the risks of full thickness skin graft which include bleeding, pain, infection, damage to surrounding tissue, scarring, asymmetry, loss of skin graft and need for further surgery.  Informed consent was obtained.
+The operation began with preparation of the wound bed.  The skin edges were debrided with a fresh 15 blade down to the level of the wound.  The wound was then debrided of excess granulation, retained vac sponge, and debris with a 10 blade and with 2 liters of antibiotic irrigation delivered with pulse lavage.  I then measured the wound and it was  cm.
-I then began the flap elevation of the ??? VRAM. The pedicle was dopplered and found to be intact. A ??? cm wide VRAM was designed around the periumbilical perforators. The skin was incised and beveled out. The flap was then elevated to the most lateral lateral row perforator to preserve as much fascia as possible for abdominal closure. The flap was then elevated from distal to proximal. The DSEA was divided and controlled with medium clips. The pedicle was protected in its entirety.
+This was then transferred to x and an ellipse was designed.  The full thickness skin graft was obtained and thinned and pie crusted on the back table.  It was placed on the wound bed and secured with 4-0 chromic sutures.  Adaptic, bacitracin, and a wound vacuum were then placed at 75mmHg.   The donor site was closed with 3-0 monocryl deep dermal layer followed by 4-0 monocryl suture.
-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 proximal portion of the skin was de-epithelialized and the flap was passed into the pelvis. The flap passed easily into the perineum with the muscle obliterating the floor of the pelvis. The muscle was inset with 3-0 pds and a 15 blake placed to drain the superficial perineal space. The skin was then inset with 3-0 pds for the deep dermal layer followed by 3-0 pds for the skin.
-===== Expectations =====
+</WRAP>
+<WRAP half column>
-Consent forms: Ensure that the consent form includes all relevant risk and alternatives of surgery. Or he will not start case and re-consent family member.
+Tourniquet: No\\
+Drain: No\\
+Sutures: 4-0 chromic sutures, 3-0 monocryl deep dermal layer followed by 4-0 monocryl suture\\
+Dressing: Adaptic, bacitracin\\
-===== Plastic Surgery Tables =====
-[[https://docs.google.com/spreadsheets/d/16Eq3hWL8YDgbPoGOnmT8e-YvJ17hiAnCqzXMVqf-B_w/htmlview]]
+</WRAP>
+</WRAP>