Plastics

User Tools

Site Tools

Trace:
resident:tae_chong

Differences

This shows you the differences between two versions of the page.

Link to this comparison view

Both sides previous revisionPrevious revision
Next revision		Previous revision
resident:tae_chong [2019/12/04 21:31] – [Panniculectomy] melissaresident:tae_chong [2021/02/22 09:36] (current) – [Facial Artery Dissection] michael
Line 24: Line 24:
 Interests and Activities: Marathons, obstacle races, soccer, and martial arts. Interests and Activities: Marathons, obstacle races, soccer, and martial arts.
  
-Operations below. He very much enjoys asking [[resident:pimp_questions|Questions]]. Here are Dr. Chong's [[resident:expectations|Expectations]] and tips for meeting them. 
  
 +=====Operating Reports=====
  
-===== Breast Reconstruction =====+General Tips:\\ 
 +[[medical_student:diep_post-op_protocol|Dr. Chong's DIEP Post-Op Protocol]]\\
  
-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 Avaguard.\\+===== Breast Reconstruction ===== 
 + 
 +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
  
  
Line 37: Line 40:
  
  
-=====Operating Reports=====+
  
 ==== Latissimus Muscle Flap ==== ==== Latissimus Muscle Flap ====
Line 53: Line 56:
 <WRAP half column> <WRAP half column>
  
-{{:resident:latissimus2.jpg|}} +{{:resident:screen_shot_2020-04-13_at_4.11.34_pm.png?400|}}
- +
-lkjfdsalkfj;lkdsajf;ldsakj +
  
 </WRAP> </WRAP>
Line 76: Line 76:
  
 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.\\
Line 97: Line 99:
 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> 
  
 Bed: **Make sure the bed is able to reflex appropriately before the case** Bed: **Make sure the bed is able to reflex appropriately before the case**
Line 129: Line 127:
 Questions you will be asked: 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. 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\\
 +
  
  
Line 159: Line 167:
 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 3-0 pds suture\\
 +Dressing: No\\
 +
  
  
Line 197: Line 211:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 232: Line 252:
    
 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.
- 
-</WRAP> 
- 
-<WRAP half column> 
  
 Surgical Steps:\\ Surgical Steps:\\
Line 255: Line 271:
 15. Dermabond incision and steristrip tails.\\ 15. Dermabond incision and steristrip tails.\\
 16. Finish one side before starting the other.\\ 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\\
 +
    
  
Line 285: Line 311:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 332: Line 364:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 374: Line 412:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 415: Line 459:
 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: 15 blake\\
 +Sutures: No\\
 +Dressing: No\\
 +
  
 </WRAP> </WRAP>
Line 424: Line 474:
 <WRAP group> <WRAP group>
 <WRAP Half Column> <WRAP Half Column>
- 
-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:  Symptomatic gynecomastia\\ Preop Dx:  Symptomatic gynecomastia\\
Line 455: Line 500:
 </WRAP> </WRAP>
 <WRAP half column> <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>
 </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 479: 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 501: Line 572:
  
 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\\
 +
 +
 +</WRAP>
 +</WRAP>
 +
  
  
  
 ====Tissue Expander==== ====Tissue Expander====
-<WRAP group>+ 
 +<WRAP Group>
 <WRAP half column> <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.\\
  
Line 519: Line 605:
  
 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.
- 
-</WRAP> 
- 
-<WRAP half column> 
  
 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\\ 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\\
Line 529: Line 611:
  
 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.\\ 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\\ 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. 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.
Line 548: Line 627:
  
 Places TE central tab at breast meridian. (he uses a grid so breast surgeon doesn't wash away his breast IMF lines).  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>
Line 553: Line 644:
 ==== 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 564: 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 589: 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 612: 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>
 +
  
  
Line 636: Line 773:
  
 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.  
- 
-</WRAP> 
- 
-<WRAP half column> 
  
 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.\\ 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.\\
Line 671: Line 804:
 1. What are indications for surgery? symptomatic macromastia with shoulder, back, and neck pain which have been refractory to any conservative measures.\\ 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.\\ 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\\
  
  
Line 677: Line 819:
  
 ==== 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 704: 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 709: Line 868:
  
 ==== Blepharoplasty ==== ==== Blepharoplasty ====
 +
 +<WRAP Group>
 +<WRAP half column>
  
 Preop Dx:  Bilateral upper lid dermatochalasis\\ Preop Dx:  Bilateral upper lid dermatochalasis\\
Line 726: 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 ==== 
Line 747: Line 922:
 </WRAP> </WRAP>
 <WRAP half column> <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 772: Line 953:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 788: Line 975:
 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +
 +
  
 </WRAP> </WRAP>
Line 795: Line 985:
 ==== STA Dissection ==== ==== STA Dissection ====
  
-<WRAP Group>+<WRAP>
 <WRAP half column> <WRAP half column>
  
Line 802: Line 992:
 </WRAP> </WRAP>
 <WRAP half column> <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>
 </WRAP> </WRAP>
 +
 +
 +
  
 ==== Facial Artery Dissection ==== ==== Facial Artery Dissection ====
  
-<WRAP Group> +<WRAP> 
-<WRAP half column>+<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.   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.  
Line 817: Line 1016:
 </WRAP> </WRAP>
 <WRAP half column> <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>
 </WRAP> </WRAP>
 +
  
 ==== Gracilis Muscle Flap to Perineum ==== ==== Gracilis Muscle Flap to Perineum ====
Line 825: Line 1034:
 <WRAP half column> <WRAP half column>
  
-Operative Report+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 840: Line 1050:
 Procedure: gracilis muscle flap to perineum, SPY indocyanine green fluorescence angiography\\ 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\\ 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\\ 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)\\ 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)\\
Line 845: Line 1066:
 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.\\ 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.\\
  
- 
-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).\\ 
  
 Questions you will be asked:\\ Questions you will be asked:\\
Line 856: Line 1075:
 6. What is the Insertion of the gracilis muscle? Medial surface of the tibia via the Pes Anserinus "goose foot".\\ 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.\\ 7. What other muscles insert at the pes anserinus? sartorius, gracilis, semitendinosus.\\
- 
-</WRAP> 
- 
-<WRAP half column> 
  
  
Line 890: Line 1105:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 922: Line 1143:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 962: Line 1189:
 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet:  arm\\ 
 +Drain: No\\
 +Sutures: 11-0 nylon, 4-0 nylon\\
 +Dressing: No\\
 +
  
 </WRAP> </WRAP>
Line 995: Line 1228:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 1006: Line 1245:
 <WRAP Group> <WRAP Group>
 <WRAP half column> <WRAP half column>
- 
  
 Preop Dx:  Sternal wound infection Preop Dx:  Sternal wound infection
Line 1047: Line 1285:
 </WRAP> </WRAP>
 <WRAP half column> <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>
Line 1085: Line 1329:
 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: Leg\\
 +Drain: No\\
 +Sutures: 3-0 pds suture,4-0 chromic\\
 +Dressing: Bio occlusive, bacitracin and adaptic\\
 +
  
 </WRAP> </WRAP>
Line 1120: Line 1370:
 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: 15 blake\\
 +Sutures: 3-0 pds\\
 +Dressing: No\\
 +
  
 </WRAP> </WRAP>
Line 1152: Line 1408:
 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 4-0 chromic sutures\\
 +Dressing: Tegaderm, Adaptic, bacitracin\\
 +
  
 </WRAP> </WRAP>
Line 1170: Line 1432:
 </WRAP> </WRAP>
 <WRAP half column> <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>
 </WRAP> </WRAP>
resident/tae_chong.1575513114.txt.gz · Last modified: 2019/12/04 21:31 by melissa
Donate Powered by PHP Valid HTML5 Valid CSS Driven by DokuWiki