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resident:tae_chong [2019/10/06 12:20] – melissaresident:tae_chong [2021/02/22 09:36] (current) – [Facial Artery Dissection] michael
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 ===== Dr. Tae W Chong Introduction ===== ===== Dr. Tae W Chong Introduction =====
  
-[[https://drive.google.com/open?id=1BmQYXNhAOHBFNVsgACDK_n42880pMWYx|Dr. Chong Publications Link]] +[[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]]
-  * Undergrad / Major +
-  * Training +
-  * General Surgery +
-  * Plastic Surgery +
-  * Fellowship - none+
  
 Degrees:  Degrees: 
- 
   * Bachelor of Science, Biology 8/90 – 6/94, College of William and Mary, Williamsburg, VA   * 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   * Doctor of Medicine 8/96 – 6/00, University of Virginia, Charlottesville, VA
  
 Training:  Training: 
- 
   - General Surgery Internship, Categorical 7/00 – 6/01, University of Chicago, Chicago, IL   - 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   - General Surgery Residency, Categorical 7/01 – 6/07, University of Virginia, Charlottesville, VA
   - Research Fellow, Transplantation & Infectious Disease 7/02 - 6/04, University of Virginia, Charlottesville, VA   - Research Fellow, Transplantation & 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   - 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
  
-  * Associate Program Director Plastic Surgery Residency 2011 - 2015 +Research Interests:\\
-  * Department of Plastic and Reconstructive Surgery +
-  * University of Texas Southwestern Medical Center +
- +
-Research Interests +
 1. Clinical reconstructive transplantation – evaluating hand transplant outcomes and optimizing medical 1. Clinical reconstructive transplantation – evaluating hand transplant outcomes and optimizing medical
-management of the recipient. +management of the recipient.\\ 
-2. Surgical Management of Lymphedema +2. Surgical Management of Lymphedema\\ 
-3. Outcomes in the reconstruction of cancer and post-traumatic defects. +3. Outcomes in the reconstruction of cancer and post-traumatic defects.\\ 
-4. Surgical and adjuvant therapy for the treatment and prevention of hypertrophic scars and keloids.+4. Surgical and adjuvant therapy for the treatment and prevention of hypertrophic scars and keloids.\\
  
-Interests and Activities+Interests and Activities: Marathons, obstacle races, soccer, and martial arts.
  
-Marathons, obstacle races, soccer, and martial arts. 
  
 +=====Operating Reports=====
  
-Operations below. He very much enjoys asking [[resident:pimp_questions|Questions]]. Here are Dr. Chong's [[resident:expectations|Expectations]] and tips for meeting them.+General Tips:\\ 
 +[[medical_student:diep_post-op_protocol|Dr. Chong's DIEP Post-Op Protocol]]\\
  
  
 ===== Breast Reconstruction ===== ===== Breast Reconstruction =====
  
-Know Base Width in chart and what patient desires for breast size (smaller, same, fuller).\\+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 
 + 
 + 
 +==== Infected or Exposed Breast Implant ==== 
 + 
  
-Scrub: For any implant cases, Chong requires you to first scrub and then use Avaguard.\\ 
  
 ==== Latissimus Muscle Flap ==== ==== Latissimus Muscle Flap ====
 +<WRAP group>
 +<WRAP half column>
 +
 Drains: Donor site: 15 blake\\ Drains: Donor site: 15 blake\\
 Sutures: Deep dermal 3-0 monocryl, Subcuticular 4-0 monocryl\\ Sutures: Deep dermal 3-0 monocryl, Subcuticular 4-0 monocryl\\
Line 54: Line 52:
 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.   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.  
  
-==== DIEP ==== +</WRAP>
-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\\+
  
-Drapes: Blue towels and staples, 4 folding sheets, ioban\\+<WRAP half column> 
 + 
 +{{:resident:screen_shot_2020-04-13_at_4.11.34_pm.png?400|}} 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
 + 
 +==== DIEP ==== 
 +<WRAP group> 
 +<WRAP half column>
  
 Preop Dx:  history of breast cancer, s/p mastectomy and now with deformity and disproportion\\ Preop Dx:  history of breast cancer, s/p mastectomy and now with deformity and disproportion\\
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 2.  SPY fluorescence imaging of skin perfusion based on perforator dissection\\ 2.  SPY fluorescence imaging of skin perfusion based on perforator dissection\\
 Drains: 2 drains in the donor site and one drain in each breast\\ Drains: 2 drains in the donor site and one drain in each breast\\
-Inset changed due to implantable doppler: \\ 
  
-Operative Report\\ +**Operative Report**\\ 
-We utilized a two team approach. My partner exposed the mammary vessels. +We utilized a two team approach. My partner exposed the mammary vessels. \\
  
 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.\\ 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.\\
 +
 +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 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.\\ 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.\\
  
-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.//\\+During this time we began the flap elevation portion of the operation by making the superior incision.  This was carried to the xiphoid and costal margin.  The patient was flexed and the lower incision line was confirmed.  We then made lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for 6cm. The flap dissection was then carried down to the rectus fascia.\\
  
 We then elevated the flap from lateral to medial. 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 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. \\
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 At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.  At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler. 
  
-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. + 
 +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\\ 
 + 
 +Drapes: Blue towels and staples, 4 folding sheets, ioban strips\\ 
 + 
 +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.\\ 
 + 
 + 
 +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. 
 + 
 +Take a rib or otherwise you are doing a vertical anastamosis. Lever up with rouncher. Never point freer towards vessels. Always towards cartilage/perichondrium. 
 + 
 +Questions you will be asked: 
 +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. 
 + 
 +</WRAP> 
 + 
 +<WRAP half column> 
 + 
 +Tourniquet: No\\ 
 +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\\ 
 + 
 + 
 + 
 +</WRAP> 
 +</WRAP> 
 + 
  
 ==== IMA Exposure ==== ==== IMA Exposure ====
 +
 +Operative Report
 +
 +<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.   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.  
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 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. 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.
 +
 +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. 
 +
 +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.
 +
 +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.
 +
 +</WRAP>
 +<WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 3-0 pds suture\\
 +Dressing: No\\
 +
 +
 +
 +
 +</WRAP>
 +</WRAP>
 ==== DIEP Revision Implants ==== ==== DIEP Revision Implants ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction with DIEP flaps Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction with DIEP flaps
 Procedure:  Revision breast reconstruction with fat grafting Procedure:  Revision breast reconstruction with fat grafting
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 She was placed into a surgical bra and binder after dressings were placed on the incisions.  She was placed into a surgical bra and binder after dressings were placed on the incisions. 
 +
 +</WRAP>
 +<WRAP half column>
 +
 +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\\
 +
 +
 +</WRAP>
 +</WRAP>
  
 ==== Tissue Expander Exchange for Implants ==== ==== Tissue Expander Exchange for Implants ====
 +<WRAP group>
 +<WRAP half column>
 +
 Preop Dx:  ??? breast mastectomy, history of ?\\ Preop Dx:  ??? breast mastectomy, history of ?\\
 Procedure:  ??? breast TE exchange, \\ Procedure:  ??? breast TE exchange, \\
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 Dermabond was applied and the patient was placed into a surgical bra. The patient was extubated and transferred to recovery in stable condition. Dermabond was applied and the patient was placed into a surgical bra. The patient was extubated and transferred to recovery in stable condition.
 +
 +Surgical Steps:\\
 +1. Know BW and fill levels as well as radiation\\
 +Radiation will change the nipple position and skin color\\
 +2. Use old incisions\\
 +3 Dissect to capsule/alloderm. Alloderm will form new IMF\\
 +4. Make new incision in capsule that is offset from skin incision (approximately 8mm-1cm superior)\\
 +5. Cut sutures to TE. Puncture and then take it out.\\
 +6. Pick your implant. The most important factor is Base-width. Try to match with TE.\
 +7. Put the sizer in to check that you like it\\
 +8. take out the sizer. \\
 +9. Irrigate the pocket\\
 +10. betadyne the skin\\
 +11. Betadyne all instruments from now on\\
 +12. Put in implant\\
 +13. Close the capsule, bury knots\\
 +14. Close the skin 3-0, 4-0 monocryl\\
 +15. Dermabond incision and steristrip tails.\\
 +16. Finish one side before starting the other.\\
 +
 +</WRAP>
 +
 +<WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 3-0 monocryl, running pullout 4-0 monocryl\\
 +Dressing: Dermabond\\
 +
    
 +
 +</WRAP>
 +</WRAP>
 ==== Top Surgery ==== ==== Top Surgery ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Preop Dx:  Gender affirmation surgery, top surgery candidate Preop Dx:  Gender affirmation surgery, top surgery candidate
 Procedure:  Bilateral subcutaneous mastectomy and free nipple graft Procedure:  Bilateral subcutaneous mastectomy and free nipple graft
Line 187: Line 308:
    
 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.   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.  
 +
 +</WRAP>
 +<WRAP half column>
 +
 +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\\
 +
 +
 +</WRAP>
 +</WRAP>
  
 ==== Unilateral DIEP ==== ==== Unilateral DIEP ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Preop Dx:  ??? breast cancer  Preop Dx:  ??? breast cancer 
Line 223: Line 360:
  
 At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.  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\\
 +
 +
 +</WRAP>
 +</WRAP>
 +
  
 ==== Direct To Implant ==== ==== Direct To Implant ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Preop Dx:  BRCA gene test positive, s/p bilateral mastectomy Preop Dx:  BRCA gene test positive, s/p bilateral mastectomy
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 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.  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. 
 +
 +
 +</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\\
 +
 +
 +</WRAP>
 +</WRAP>
 +
  
 ==== DIEP Takeback ==== ==== DIEP Takeback ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Consent:\\ Consent:\\
Line 284: Line 457:
 Only remove A FEW staples if you think there is venous congestion. Hematoma should be handled in OR Only remove A FEW staples if you think there is venous congestion. Hematoma should be handled in OR
  
 +</WRAP>
 +<WRAP half column>
  
-==== Gynecomastia ==== +Tourniquet: No\\ 
-Sutures: 3-0, 4-0 monocryl\\ +Drain: 15 blake\\ 
-Dressing: 1 inch steri strips, compressive ACE or breast binder\\ +Sutures: No\\ 
-Drains: 15 blake round if large resection. Come out lateral and inferior to IMF.\\+Dressing: No\\
  
 +
 +</WRAP>
 +</WRAP>
 +
 +
 +
 +==== Gynecomastia ====
 +<WRAP group>
 +<WRAP Half Column>
  
 Preop Dx:  Symptomatic gynecomastia\\ Preop Dx:  Symptomatic gynecomastia\\
Line 312: 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.   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.  
  
 +What is saucer deformity? By making a peri-areolar deformity can get a saucer deformity. (Like the indent in a saucer plate for tea).
 +
 +</WRAP>
 +<WRAP half column>
 +
 +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.\\
 +
 +</WRAP>
 +</WRAP>
 ==== BBA, Lipo, Abdominoplasty ==== ==== BBA, Lipo, Abdominoplasty ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Preop Dx:  Breast ptosis, abdominal lipodystrophy, abdominal diastasis Preop Dx:  Breast ptosis, abdominal lipodystrophy, abdominal diastasis
 Procedure:  Bilateral breast augmentation, liposuction of abdomen, and abdominoplasty Procedure:  Bilateral breast augmentation, liposuction of abdomen, and abdominoplasty
Line 333: Line 533:
  
 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.  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 ==== ==== Breast Augmentation ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Preop Dx:  Breast ptosis, hypomastia Preop Dx:  Breast ptosis, hypomastia
Line 356: Line 573:
 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 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\\
  
-====Tissue Expander==== 
-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.\\+</WRAP> 
 +</WRAP>
  
-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.\\ 
-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.+ 
 + 
 +====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.\\ 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.+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 {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.+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. 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.+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 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+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. 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.
  
-1. Know BW and fill levels as well as radiation\\ +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\\ 
-Radiation will change the nipple position and skin color\\ + 
-2. Use old incisions\\ +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.\\ 
-3 Dissect to capsule/alloderm. Alloderm will form new IMF\\ + 
-4. Make new incision in capsule that is offset from skin incision (approximately 8mm-1cm superior)\\ +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.\\ 
-5. Cut sutures to TE. Puncture and then take it out.\\ +Irrigation: 1L baci irrigation with cysto tubing\\ 
-6. Pick your implant. The most important factor is Base-width. Try to match with TE.\ + 
-7. Put the sizer in to check that you like it\\ +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. 
-8. take out the sizer. \\ + 
-9. Irrigate the pocket\\ +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.\\
-10. betadyne the skin\\ +
-11. Betadyne all instruments from now on\\ +
-12. Put in implant\\ +
-13. Close the capsule, bury knots\\ +
-14. Close the skin 3-0, 4-0 monocryl\\ +
-15. Dermabond incision and steristrip tails.\\ +
-16. 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.\\ 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.\\
Line 407: Line 623:
 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.\\ 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\\ 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 ==== ==== Breast Fat Grafting ====
  
-Suture: 4-0 chromic simple interrupted to close stab incisions for liposuction and fat grafting.\\ +<WRAP Group> 
-Dressing: Bacitracin and band-aid over each site.\\+<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.\\ 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.\\
Line 421: Line 655:
  
 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.\\ 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>
 +
  
 ==== Nipple Reconstruction ==== ==== Nipple Reconstruction ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction. Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction.
Line 446: 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. 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 ==== ==== Oncoplastic Reconstruction ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Preop Dx:  History of lumpectomy, deformity of breast Preop Dx:  History of lumpectomy, deformity of breast
 Procedure: oncoplastic reconstruction Procedure: oncoplastic reconstruction
Line 469: Line 736:
  
 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. 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.
 +
 +</WRAP>
 +<WRAP half column>
 +
 +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\\
 +
 +
 +</WRAP>
 +</WRAP>
 +
  
  
 ==== Bilateral Breast Reduction ==== ==== Bilateral Breast Reduction ====
 +<WRAP group>
 +<WRAP half column>
 +
 Preop Dx:  Symptomatic macromastia Preop Dx:  Symptomatic macromastia
 Procedure:  Bilateral breast reduction Procedure:  Bilateral breast reduction
Line 477: Line 760:
 Complications:  None  Complications:  None 
 Findings:   Bilateral viable NAC 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. 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 493: 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.   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:\\
 +1. Mark NAC with 38 mm cookie cutter.\\
 +2. Use 15 blade around the NAC to start de-epi.\\
 +3. Breast tourniquet with lap pad (Roll and Twist) and Kocker.\\
 +4. Continue de-epi inferiorly as far as you can go.\\
 +5. Take down tourniquet and use Face Lift scissors to complete de-epi of central/inferior pedicle.\\
 +6. 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.**\\
 +7. 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.\\
 +8. Complete the superior incision to free your pedicle **without undermining the pedicle**.\\
 +9. 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.//
 +10. 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.\\
 +11. 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.\\
 +12. 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)\\
 +13.  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.\\
 +14. Staple at 12, 3, 6, 9 and then staples in between. Close with 4-0, 5-0 monocryl.\\
 +15. 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\\
 +
 +1. What are indications for surgery? symptomatic macromastia with shoulder, back, and neck pain which have been refractory to any conservative measures.\\
 +2. 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 ==== ==== Breast Revision ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Preop Dx:  Deformity and disproportion of reconstructed breasts, history of breast cancer reconstruction 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. Procedure:  Revision breast reconstruction with fat grafting, revision of donor site (abdomen), and breast mastopexy - bilateral.
Line 524: Line 850:
  
 Fat Grafting -> ABX course 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>
 +
  
  
Line 529: Line 868:
  
 ==== Blepharoplasty ==== ==== Blepharoplasty ====
 +
 +<WRAP Group>
 +<WRAP half column>
  
 Preop Dx:  Bilateral upper lid dermatochalasis\\ Preop Dx:  Bilateral upper lid dermatochalasis\\
Line 546: Line 888:
  
 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.  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 ====  ==== Panniculectomy ==== 
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 +
 Preop Dx:  Panniculitis, excess abdominal skin\\ Preop Dx:  Panniculitis, excess abdominal skin\\
 Procedure:  panniculectomy\\ Procedure:  panniculectomy\\
Line 559: Line 919:
  
 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 . 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>
  
  
Line 565: Line 937:
  
 ==== Abdominoplasty ==== ==== Abdominoplasty ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Pre-op: Mark the position of the lower incision and the scar\\ Pre-op: Mark the position of the lower incision and the scar\\
 Position: Supine\\ Position: Supine\\
Line 573: Line 949:
 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 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.  +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 ===== ===== Other Microsurgery =====
  
 ==== PT Dissection ==== ==== 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.  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 ==== ==== 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.   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 ==== ==== 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.  + 
 +<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.   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 ==== ==== Gracilis Muscle Flap to Perineum ====
-Procedure: gracilis muscle flap to perineum, SPY indocyanine green fluorescence angiography\\ +<WRAP group> 
-Markings: Frog leg patient. Adductor longus should be bowed out muscle and mark entire course to knee. Mark gracilis 2 finger breadths below +<WRAP half column> 
-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)\\ +Operative Report:\\
-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 
 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 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. 
  
Line 610: Line 1048:
 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 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).+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\\
  
-Pimp questions: +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).\\
-1. What superficial vein may you encounter during dissection? Greater saphenous vein +
-2. 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. +
-3. Describe course of medial femoral circumflex artery? Between adductor magnus and longus. +
-4. What nerve supplies the gracilis muscle? anterior branch of obturator.+
  
 +</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:\\
 +1. What superficial vein may you encounter during dissection? Greater saphenous vein\\
 +2. 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.\\
 +3. Describe course of medial femoral circumflex artery? Between adductor magnus and longus.\\
 +4. What nerve supplies the gracilis muscle? anterior branch of obturator.\\
 +5. What is the Origin of the gracilis muscle? The pubic symphysis and the inferior pubic ramus.\\
 +6. What is the Insertion of the gracilis muscle? Medial surface of the tibia via the Pes Anserinus "goose foot".\\
 +7. What other muscles insert at the pes anserinus? sartorius, gracilis, semitendinosus.\\
 +
 +
 +</WRAP>
 +</WRAP>
  
 ==== Gracilis Free Flap ==== ==== Gracilis Free Flap ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Procedure:  Perineal reconstruction with gracilis flap Procedure:  Perineal reconstruction with gracilis flap
 SPY indocyanine green fluorescence angiography  SPY indocyanine green fluorescence angiography 
Line 637: Line 1102:
  
 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. 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 ==== ==== Gastrocnemius Muscle Flap ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Preop Dx:  Composite wound of the proximal tibia with exposed bone Preop Dx:  Composite wound of the proximal tibia with exposed bone
Line 659: Line 1141:
 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.   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 ==== ==== Lymphatico venous bypass ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Preop Dx:  Lymphedema of the  arm Preop Dx:  Lymphedema of the  arm
Line 690: Line 1187:
 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.  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 ==== ==== Soleus Muscle Flap ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Preop Dx:  Composite wound of the ? middle tibia with unstable scar and underlying osteomyelitis Preop Dx:  Composite wound of the ? middle tibia with unstable scar and underlying osteomyelitis
Line 713: Line 1225:
  
 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.   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.  
 +
 +</WRAP>
 +<WRAP half column>
 +
 +Tourniquet: Leg\\
 +Drain: 10 blake\\
 +Sutures: 3-0 pds, 2-0 nylon, 4-0 chromic\\
 +Dressing: bio occlusive, bacitracin and adaptic\\
 +
 +
 +</WRAP>
 +</WRAP>
 +
  
  
  
 ==== Bilateral pectoralis Muscle Flaps ==== ==== Bilateral pectoralis Muscle Flaps ====
 +
 +<WRAP Group>
 +<WRAP half column>
  
 Preop Dx:  Sternal wound infection Preop Dx:  Sternal wound infection
Line 754: Line 1282:
 Strict sternal precuations Strict sternal precuations
 No heavy lifting" 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 ==== ==== Reverse Sural Flap ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
 Preop Dx:  Composite wound of the ???with exposed hardware and with unstable scar. 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. Procedure:  Debridement of wound (skin, fascia ???), preparation of wound bed ???, reverse sural flap, split thickness skin graft ??? cm incisional wound vacuum >50cm2.
Line 782: 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. 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.
  
 +</WRAP>
 +<WRAP half column>
 +
 +Tourniquet: Leg\\
 +Drain: No\\
 +Sutures: 3-0 pds suture,4-0 chromic\\
 +Dressing: Bio occlusive, bacitracin and adaptic\\
 +
 +
 +</WRAP>
 +</WRAP>
  
  
  
 ==== Vertical Rectus Abdominis Muscle Flap ==== ==== Vertical Rectus Abdominis Muscle Flap ====
 +
 +<WRAP Group>
 +<WRAP half column>
  
 Preop Dx: Large perineal wound after resection of ??? Preop Dx: Large perineal wound after resection of ???
Line 808: Line 1367:
  
 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 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. 
 +
 +</WRAP>
 +<WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: 15 blake\\
 +Sutures: 3-0 pds\\
 +Dressing: No\\
 +
 +
 +</WRAP>
 +</WRAP>
 +
  
  
 ==== Split Thickness Skin Graft ==== ==== Split Thickness Skin Graft ====
 +
 +<WRAP Group>
 +<WRAP half column>
 +
  
 Procedure:  Preparation of wound bed ? cm2   Procedure:  Preparation of wound bed ? cm2  
Line 829: Line 1405:
  
 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.  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. 
 +
 +</WRAP>
 +<WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 4-0 chromic sutures\\
 +Dressing: Tegaderm, Adaptic, bacitracin\\
 +
 +
 +</WRAP>
 +</WRAP>
  
  
 ==== Full Thickness Skin Graft ==== ==== Full Thickness Skin Graft ====
 +
 +<WRAP Group>
 +<WRAP half column>
  
 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.   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.  
Line 838: Line 1429:
  
 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.  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. 
 +
 +</WRAP>
 +<WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 4-0 chromic sutures, 3-0 monocryl deep dermal layer followed by 4-0 monocryl suture\\
 +Dressing: Adaptic, bacitracin\\
 +
 +
 +</WRAP>
 +</WRAP>
resident/tae_chong.1570378825.txt.gz · Last modified: 2019/10/06 12:20 by melissa
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