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resident:tae_chong [2019/12/04 21:39] – [Tissue Expander Exchange for Implants] melissaresident:tae_chong [2021/02/22 09:36] (current) – [Facial Artery Dissection] michael
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 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
  
  
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-=====Operating Reports=====+
  
 ==== Latissimus Muscle Flap ==== ==== Latissimus Muscle Flap ====
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 <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>
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 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.\\
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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. 
  
-  
-</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**
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 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\\
 +
  
  
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 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 3-0 pds suture\\
 +Dressing: No\\
 +
  
  
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 </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>
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 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 3-0 monocryl, running pullout 4-0 monocryl\\
 +Dressing: Dermabond\\
 +
    
  
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 </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>
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 </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>
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 </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>
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 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: 15 blake\\
 +Sutures: No\\
 +Dressing: No\\
 +
  
 </WRAP> </WRAP>
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 <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\\
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 </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>
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 </WRAP> </WRAP>
 <WRAP half column> <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>
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 </WRAP> </WRAP>
 <WRAP half column> <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>
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 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.
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 <WRAP half column> <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>
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 <WRAP Group> <WRAP Group>
 <WRAP half column> <WRAP half column>
- 
-Suture: 4-0 chromic simple interrupted to close stab incisions for liposuction and fat grafting.\\ 
-Dressing: Bacitracin and band-aid over each site.\\ 
  
 I had a long discussion about the risks of the surgery including bleeding, pain, infection, contour deformity, injury to the skin, recurrence, wound healing problems, damage to surrounding tissue, and need for further surgery.  The patient understands that she will have to wear compression garments for the postoperative care, and I want her to ambulate daily.\\ 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.\\
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 </WRAP> </WRAP>
 <WRAP half column> <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>
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 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 4-0 chromics, 3-0, 4-0 monocryl\\
 +Dressing: Dermabond, tegaderm\\
 +
  
 </WRAP> </WRAP>
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 </WRAP> </WRAP>
 <WRAP half column> <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>
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 <WRAP half column> <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\\
  
  
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 </WRAP> </WRAP>
 <WRAP half column> <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>
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 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: No\\
 +Sutures: 6-0 prolene sutures \\
 +Dressing: No\\
 +
  
 </WRAP> </WRAP>
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 </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>
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 </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>
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 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +
 +
  
 </WRAP> </WRAP>
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 ==== STA Dissection ==== ==== STA Dissection ====
  
-<WRAP Group>+<WRAP>
 <WRAP half column> <WRAP half column>
  
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 </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.  
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 </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 ====
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 <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. 
  
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 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)\\
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 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:\\
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 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> 
  
  
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 </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>
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 </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>
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 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet:  arm\\ 
 +Drain: No\\
 +Sutures: 11-0 nylon, 4-0 nylon\\
 +Dressing: No\\
 +
  
 </WRAP> </WRAP>
Line 1072: 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>
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 <WRAP Group> <WRAP Group>
 <WRAP half column> <WRAP half column>
- 
  
 Preop Dx:  Sternal wound infection Preop Dx:  Sternal wound infection
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 </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>
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 </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>
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 </WRAP> </WRAP>
 <WRAP half column> <WRAP half column>
 +
 +Tourniquet: No\\
 +Drain: 15 blake\\
 +Sutures: 3-0 pds\\
 +Dressing: No\\
 +
  
 </WRAP> </WRAP>
Line 1229: 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 1247: 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.1575513572.txt.gz · Last modified: 2019/12/04 21:39 by melissa
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