Plastics

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==== Introduction ====

Medical School: University of London, St. Bartholomew's and The Royal London School of Medicine, Medical Education (2002)\\
Residency:\\
Clochester Hospital England (2006)\\
Broomfield Hospital, England (2007)\\
UTSW General Surgery\\
UTSW Plastic Surgery Fellowship (2016)\\
MD Anderson Microsurgery Fellowship (2017)\\

[[https://drive.google.com/drive/folders/1TiUDgz4PEHCe6-wU0oKfL6llMtR8AZZO?usp=sharing|Dr. Wong Publications]]



==== Operative Reports ====

General Tips:\\
Preferred first line dressing for questionable wounds is Wet to Dry BID dressing changes.\\

==== MTF Breast Augmentation ====

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Operative Report:\\
1. MTF Breast Augmentation\\
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The patient was seen in the preoperative holding area. Preoperative markings were made with the patient standing.  The planned incision, implant type, location and approximate size were again confirmed with the patient, who understood and agreed with the operative plan.  The patient was then taken to the operative suite and placed in supine position.  All bony prominences were padded.  SCD boots were placed.  Arms were placed in 90 degrees of abduction.  Perioperative antibiotics were given.  A proper timeout was taken, which all present parties were in agreement.  General endotracheal anesthesia was administered. The patient was then prepped and draped in the usual sterile fashion.  
 
Attention was directed to the right breast.  An incision was made in the inframammary fold, about 5 cm in length.  The incision was extended through the dermis using electrocautery Bovie.  A deeper dissection was carried down to the fascia.  The inferior and lateral border of the pectoralis muscle was visualized and elevated subpectorally using electrocautery Bovie, mixed with blunt finger dissection overlying the ribs.  A retractor was inserted and the muscle and glandular breast tissue was distracted superiorly.  This was carried around medially, superiorly and laterally to the preoperative markings of the breast base. Minimal blunt dissection was performed laterally to continue gentle round smooth contour to complete the implant pocket.  Visual and manual inspection of the pocket was performed to ensure a smooth contour, as well as hemostasis. The contralateral breast pocket was made in similar fashion.


The pocket was irrigated with saline and a 365 mL breast implant sizer was placed into the left breast pocket and a 415 mL sizer was placed in the right breast pocket.The incisions were temporarily closed with staples and on visual inspection, the sizers seemed to be in a good position and was anatomically pleasing. The 415 mL sizer was chosen as best matching the patient's expectations and the patient's incisions were then opened again. Final corrections were performed to correct any asymmetry or under-dissection.   The pocket was irrigated with saline and hemostasis was excellent.  

The cavity was then irrigated with triple antibiotic solution. The incision was then re-prepped with Betadine and redraped and using a new pair of sterile surgical gloves, the 415 mL silicone implant was opened and bathed in antibiotic solution.  The implant was inserted into the subpectoral space in a minimal touch technique using a Keller funnel.  This was performed bilaterally and the incision was temporarily closed with staples.  The patient was then sat up to evaluate symmetry and evaluate the final breast shape.  The breasts were evaluated for implant position, symmetry, in both sitting and supine position, from multiple angles and any necessary adjustments in the pocket confirmation was addressed, at this time. The patient was again placed in supine position.  The new inframammary fold of the lower part of the incision was created using a 2-0 PDS, a 3 point suture tacking down the fascia to the chest wall was placed creating a new inframammary fold.  Using a 3-0 Vicryl, the superficial fascia was then re-approximated. A 3-0 Monocryl was used in interrupted fashion for deep dermal sutures and approximation of the skin was performed using a 4-0 Monocryl running subcuticular stitch.  The nipple areolar viability was reassessed and was excellent. This was repeated for the contralateral breast Exofin followed by telfa and tegaderm were then applied to the incision. 
 
Final dressing consisted of a surgical compression bra, which was placed on the patient. Anesthesia performed a regional block at the end of the case before extubation. The patient was awakened, uneventfully, from anesthesia and tolerated the procedure well.  

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Photos\\
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Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: Include restrictions, splints, etc...\\

Learning points/Pimp Questions:\\

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==== Tissue Expander ====

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Operative Report\\
Left breast reconstruction with Sub-pectoral Tissue Expander with alloderm placement\\
Implant: Allergan smooth tissue expander 133S-MX-13-T 500cc (BW 13cm)\\
Intraoperative expansion: 0cc\\

The patient was taken to the the operating room and secured with all bony prominences padded and following patient and procedure confirmation, anesthesia was started. The site was prepped and draped in usual sterile fashion. A pre-operative time-out was performed confirming site, laterality, patient and procedure to be performed.
 
A skin sparing mastectomy was performed by the Breast Surgery Team prior to the start of the the tissue expander portion. Please see Dr. Jaiswal's operative note for the technical details. We began by ensuring hemostasis of the mastectomy flaps. Next, starting at the lateral edge of the pectoralis major muscle, the muscle was raised keeping the pectoralis muscle down and the underlying pedicle in the underlying fat adherent to the muscle. The flap was raised medial to about 2cm from the sternum. The rib insertions were kept in place and in order to match the contralateral side intramammary fold, 2 cm of rectus fascia was elevated to allow for a symmetric placement of the tissue expander. The pocket for the tissue expander was irrigated and hemostasis achieved. The base width of the pocket was measured and the 13cm base width tissue expander was chosen. The pocket was irrigated with triple antibiotic solution and betadine and outer gloves were changed. The tissue expander was placed into the sub-pectoral pocket and the lateral uncovered area was marked. A piece of alloderm was cut and sutured in place using 2-0 vicryl sutures. The expander was placed in the pocket and sutured in place with 3-0 PDS sutures in the lateral and superior tabs. The alloderm was then closed over the tissue expander and sutured to the lateral edge of the pectoralis major muscle with 3-0 vicryl sutures. An 15 fr drain was placed over the muscle and alloderm. The skin was closed with 3-0 monocryl deep dermal sutures and a 4-0 monocryl running subcuticular sutures. The skin was covered with steri-strips and surgical glue.

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Photos\\


Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: General Surgery Primary (at DH)\\
3 doses of Ancef\\
5 Days of keflex\\
Record Drain output\\
The Tissue Expander was NOT filled because of active smoking history\\


Learning points/Pimp Questions:\\
Make sure to put tissue expander information and fill volume towards the top of the operative report.\\

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==== Anteriolateral thigh (ALT) free flap ====

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Operative Report
The patient was transported to Operating Room #9 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered as 2 grams of IV Cefazolin. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed.
 
Inspection of the prior propeller flap was found to be non-viable with no evidence of bleeding. This was excised in its entirety. The previously placed split-thickness skin graft remained in placed and appeared viable.
 
Using a sterile handheld Doppler, three anterolateral thigh perforators were identified on the skin and marked. A curvilinear incision was made anterior to the perforator sites using a 10-blade scalpel. Dissection was carried down to the muscle fascia using Bovie electrocautery. The fascia was then incised again using the Bovie. A subfascial plane was developed until the septocutaneous perforators were identified and preserved. The supplying descending branch of the lateral circumflex femoral artery was identified in the interval between the rectus femoris and vastus lateralis muscles. This was traced proximally and well-visualized. The pedicle was then carefully dissected out and all muscular branches were identified and ligated with surgical clips. The most proximal of the three perforators was deemed not necessary and ligated with surgical clips. 
 
Simultaneously, the lower leg wound was prepared as a recipient bed with an 8 cm by 9 cm wound. A longitudinal incision measuring 6 cm was made at the superior aspect of the wound anteriorly with a 15-blade scalpel. Dissection was carried down to the muscles and the tibialis anterior and extensor hallucis longus muscles were retracted to expose the anterior tibial artery. Two accompanying venae comitantes were identified as well. The artery and two veins were cleaned and trimmed and prepared for anastomosis with Biover microvascular clamps.
 
An 8 cm by 9 cm template was drawn onto the thigh donor site centered over the two perforators. A posterior curvilinear incision was made at the anterior border of the previously harvested skin graft using a 10-blade scalpel and carried down through the fascia using Bovie electrocautery. The subfascial plane was developed anteriorly until the two perforators were identified and preserved. The pedicle was then dissected completely free. Proximally, the descending branch of the LCFA was isolated and ligated. The two accompanying venae comitantes were similarly ligated. The anterolateral thigh flap was then passed to the lower leg wound for anastomosis. It was secured in place using 3-0 Vicryl suture.
 
The operating microscope was positioned in place and used to perform the anastomoses. The arteries and veins were cleaned and trimmed in the usual fashion. The dominant draining vein was anastomosed using a 2.5 mm venous coupler. The other vein was anastomosed using a 3.0 mm venous flow coupler. The descending branch of the LCFA was then anastomosed to the anterior tibial artery using 8-0 Nylon suture. The Biover microvascular clamps were removed with good inflow and outflow to the flap as noted by Doppler signals and appearance of the flap. The flow coupler had an intermittent signal as a result of being on the minor venous anastomosis.
 
The flap was first trimmed to fit the defect and then inset with 3-0 buried Vicryl suture and 3-0 short-segment running Nylon suture. Inferiorly, a Penrose drain was placed to facilitate drainage. The inferior aspect of the flap was stapled to the native skin. The previously trimmed portions of the flap were prepared as full-thickness skin graft to the remaining exposed wound and stapled in place. 
 
30 ml of a 1:1 mixture of 1% lidocaine and 0.25% bupivicaine was injected into the surgical sites for local analgesia.
 
The new skin graft site as well as the prior skin graft sites were dressed with bacitracin ointment and Xeroform. The incision sites were dressed with bacitracin ointment. A posterior leg splint was fashioned so as to maintain the ankle in a neutral position. The lower leg was placed in a bulky Jones dressing with an anterior window cut for flap assessment.
 
The donor site was thoroughly irrigated and adequate hemostasis obtained. The skin was undermined in all directions so as to facilitate closure. The superficial fascial system was closed using 2-0 Vicryl suture. A 19 French round Blake drain was placed and secured to the skin using 2-0 Nylon. The skin was closed using 3-0 Monocryl deep dermal sutures and 4-0 Monocryl running subcuticular. The incision was dressed with Exofin glue. The thigh was wrapped in a 6" ACE for gentle compression.
 
A 300 mg aspirin suppository was given.


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Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care: - Admit to surgical ICU for post-operative monitoring.\\
- Tropical room. Bair hugger over LLE.\\
- q1 hour flap checks: Dopplerable arterial signal x2 (BLUE stitch) and venous signal (BLACK stitch). Monitor color, skin turgor, temperature, capillary refill.\\
- Venous coupler on at all times. Coupler is on the minor vein and may not have a consistent signal. Doppler venous signal as needed.\\
- LUE elevated.\\
- Bedrest.\\
- NPO. Advance to CLD POD 1 if no issues.\\
- ASA 81 mg daily beginning POD 1. Lovenox DVT ppx.\\
- Foley in place.\\
- Left thigh drain to bulb suction.\\

Learning points/Pimp Questions:\\

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==== Pectoralis Flap (Pedicled) ====

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Operative Report\\

We began by thoroughly irrigating the wound with 3L normal saline. The defect measured 17 cm transversely and 15 cm vertically. The pectoralis major muscle fascia had been stripped bilaterally, but there was healthy granulation tissue forming. There was also a 4 cm by 5 cm muscle defect on the left. Skin flaps were raised circumferentially, more extensively to the left inferolateral direction. Once the lateral edge of the PM muscle was identified, dissection was carried in a submuscular plane. Its inferior attachments and medial attachment to the sternum were released. Its supplying pedicle, the pectoral branch of the thoracoacromial artery, was identified on the undersurface and preserved. The PM was freed from its medial clavicular attachment. The PM was then divided lateral to the pedicle for advancement and rotation.\\
 
The wound was again thoroughly irrigated and adequate hemostasis was obtained. Two 15 French round Blake drains were placed, one of the left side and one on the right side, and secured in place with 3-0 Nylon sutures. The PM muscle flap was advanced and rotated medially and superiorly to cover the exposed bone and secured in place with figure-of-eight 3-0 Vicryl suture to the chest wall. A 2-0 Monocryl suture was used to purse-string the skin flaps, leaving a 12 cm by 13 cm wound.\\
 
A 0.012" split-thickness skin graft was harvested from the left thigh and meshed in a 2:1 fashion. It was stapled in placed to the chest wound and a wound vac consisting of Xeroform and black sponge was placed over the graft. There was good suction and seal. The drains were dressed with Biopatches and Tegederm. 30 ml of 0.25% bupivicaine with 1:200,000 epinephrine was injected into the thigh donor site for local analgesia. 
The thigh donor site was dressed with Tegederm, ABD pads, Kerlix, and ACE wrap.\\
 
A post-operative block was administered by the anesthesia team. See their procedure note for details.\\

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Drains: 15 french blake x2\\

Anatomy\\
Mathes and Nahai Type V - IMA perforators and pectoral branch off thoracoacromial which is dominant.\\
Insertion is at the bicipetal groove of the humerus. Relationship of LD and teres major is "a lady between two Majors." This can be disinserted for more rotation.\\
The pedicle is in the fat superior to pectoralis minor. Burn down on the minor and not the fat or the flap will die.\\

Post-operative care: No lifting greater than 10 lbs for 2 weeks.\\

Attending Pearls\\
Start with an area that you know you can elevate. The inferior portion that you elevated for TE or breast aug is usually a safe space.\\

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==== F to M Mastectomy Double Incision with Free Nipple Grafting ====

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Operative Report\\

The patient was marked pre-operatively standing up. He was brought to the operative room and placed supine on the table. General anesthesia was administered and the patient was intubated atraumatically. SCD's were placed on bilateral lower extremities and pressure points were padded appropriately. Time out was performed, confirming patient's name, medical record number, date of birth, procedure and laterality. We infiltrated each breast with 150ml of wetting solution. This was comprised of 1L normal saline + 1mg epinephrine 1:1000. The patient's chest was prepped and draped in a sterile manner. We began by marking out the nipple areolar complexes (NAC) with the 25mm cookie cutter, and removed them with a knife as a full thickness skin graft. These were placed in a saline gauze and put on a back table. We worked on bilateral breasts simultaneously. We made the superior incision with a ten blade and Bovie, and ensured the mastectomy skin flaps were about 1.5cm, all the way down to the pectoralis fascia. We then made the inferior incision with a knife and Bovie, down to chest wall, and dissected the breast tissue off the pectoralis fascia. We then removed the breast tissue and passed them off for Pathology. We ensured hemostasis with Bovie cautery and stapled the incisions closed. We then sat the patient up and placed our NAC locations at about the 4th intercostal space, about 1.5cm superior to the incisions, and about 11cm from midline. After marking out the NAC locations, we sat the patient back down and de-epithelialized them. We removed the staples and checked the wounds again for hemostasis. We then washed out the wounds with normal saline. We placed a 15Fr drain in each wound and secured them with 3.0 Nylon. We closed the transverse incisions with  2.0 PDS in a 3 point suture, then with Vicryl 3.0, and lastly with 3.0 Covidien V-lock. These incisions were dressed with Steristrips and Dermabond. The NAC's were defatted and fenestrated with a 15 blade. These were secured on the chest with 5.0 Chromic. Bolsters made out of cotton balls, mineral oil and Xeroform were placed over the NAC grafts and tied over with 3.0 Silk. These were then covered with Tegaderms. The drains were dressed with Biopatches and Tegaderms. We then requested bilateral PECS blocks by Anesthesia, to assist in postoperative pain (please see their note for details). He was then placed in a compression vest and fluffs.  

**New** bolster instructions (as of 02/22/21):

Adaptic buttered with Bacitracin ointment over the free nipple grafts, then telfa square, then 4x4 gauze folded into a small square for some compression, then Tegaderm. Steri-strips & Exofin, per usual, on the bottom incision.

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Marks 4th intercostal space for nipple placement.\\

Drains: 2x 15 french Blake drains, 1 on each side\\
Dressing: Prineo (or steri-strips and surgical glue), telfa bolster, cover everything in telfa tegaderm, biopatch and tegaderm for the drain. Bolster bacitracin, 3 layered telfa, tegaderm. **No longer using suture bolster**.\\
Sutures: 2-0 PDS 3 point stitch. 3-0 nylon for drain. 3-0 silk for bolster. 3-0 vicryl for "SFS", 3-0 v-lock.\\

Draping: 1) Drape arms with mayo stand covers, 2) Tuck half sheets into patient's sides, 3) Surround surgical site with green towels, staple in place. Make sure towels are as low as possible to OR table. 4) U drapes above and below waist 

Resident tips:\\
Like usual for Dr. Wong breast cases, start with 150 cc of epi tumescence (without local anasthetic) infiltration into each breast using spinal needles and 50 cc syringes.\\
Dr. Wong likes POST-operative blocks (anasthesia choice: pectoralis, paravertebral etc..) after the case and before extubation.\\
For double incision approach, Dr. Wong does not obliterate the IMF. She infact uses three 2-0 PDS sutures with 3 points to preserve it while closing.\\
If breasts are not ptotic, then you have to match the lower line to the upper which you set just above the pigmented areola instead of the usual matching the upper incision to pitanguy's point.\\
She usually starts at the inferior markings, but in case of non-ptotic breasts, she will start at the superior incision.\\
Match thickness of flap to belly flap.\\
Feel free to <del>grope</del> palpate Dr. Wong's side as much as you need.\\
This operation is hard to do without assistance. Be careful not to button hole skin if you don't have an assistant.\\
Dr. Wong uses 10 blade to excise through breast tissue.\\
Measures nipple placement. Usually about 11-13 cm from midline and 2-3 cm above IMF. Uses the eye test. Remember they are more lateral than female nipples.\\
To thin nipples, take 4 mosquito clamps N / S / E / W and pinch dermis, not epidermis. Thin with mayo scissors over your finger. Beware of your depth. Fenestrate x 5 with 15 blade.\\

Post-Operative Instructions:\\
- Okay to shower after 48 hours\\
- Okay to remove dressing except for drains and yellow bolster in 48 hours\\
- No lifting greater than 5 lbs\\
- Please call to confirm your follow up in 1 week\\
- No NSAIDs for 2 days\\

**For the Adaptic/bacitracin ointment/Telfa, no suture bolster:**
**All dressings stay on until their next follow-up**.

(Dr. Malliaris is still doing the Xeroform, cotton balls, mineral oil, sutured bolster & Tegaderm off after 48 hrs).

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==== F to M Mastectomy Peri-Areolar (Ω incision) with Inferior Dermoglandular Pedicle ====

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Operative Report\\

The operative area was infiltrated with 120 mL into each breast of tumescent fluid.  Tumescent fluid consisted of 1 liter of normal saline, and 1 mL of epinephrine 1:1000. \\
 
The inferiorly based dermoglandular nipple areolar complex (NAC) pedicle was marked as well as a superior omega incision marked. A 25 mm cookie cutter was then used to mark the NAC.The pedicle was de-epithelized with #15 and #10 blades leaving the NAC in place, taking care not to injury the NAC. The superior omega incision was made sharply and using electrocautery bovie a superiorly based subcutaneous flap was created to match the patients abdominal wall thickness. The dissection continued to two finger breaths below the clavicle and one finger breath from midline. Next, the an inferior flap was created leaving a 2cm dermoglandular pedicle posterior to the NAC. The dissection continued two finger breaths below the intramammary fold in order to obliterate it. With the flaps complete, the breast tissue was dissected off the chest wall with the electrocautery. Both side flap thicknesses were compared and matched by removing additional tissue with curved mayo scissors. Hemostasis was obtained. The pockets were irrigated. 15 french drains were placed in each side.\\
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The dermoglandular pedicle and incision were stapled in place. The skin was tailor tacked and the dermoglandular pedicles were expanded on each side to remove lax skin. The marked areas were de-epithelized. The omega incision deep tissue was closed with 2-0 vicryl sutures. The dermis was closed with 3-0 monocryl followed by a 4-0 monocryl subcuticular suture. A central small wedge of the NAC was excised in order to reduce the projection of the NAC. This was closed with a 5-0 prolene suture.\\
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The incisions were dressed with steri-strips and exofin glue was placed on the steri-strips boarding the NAC. A Biopatch  and tegaderm were placed over the drain sites.  Tegaderm and telfa were placed over the incisions. A compression garment was placed on the patient's chest.\\

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Marks 4th intercostal space for nipple placement.\\

Drains: 2x 15 french Blake drains, 1 on each side\\
Dressing: Prineo (or steristrips and glue), telfa tegaderm, biopatch and tegaderm for the drain.\\
Sutures: 2-0 vicryl deep. 3-0 nylon for drain. 3-0 deep dermaland 4-0 monocryl subcuticular.

Draping: 1) Drape arms with mayo stand covers, 2) Tuck half sheets into patient's sides, 3) Surround surgical site with green towels, staple in place. Make sure towels are as low as possible to OR table. 4) U drapes above and below waist 

Resident tips:\\
Like usual for Dr. Wong breast cases, start with 120-180 cc of epi tumescence (without local anasthetic) infiltration into each breast using spinal needles and 50 cc syringes.\\
Dr. Wong likes POST-operative blocks (anasthesia choice: pectoralis, paravertebral etc..) after the case and before extubation.\\
Mark 4th interocostal space.\\
Inferior dermoglandular pedicle with superior omega incision.\\
Match thickness of flap to belly flap.\\
Feel free to <del>grope</del> palpate Dr. Wong's side as much as you need.\\
This operation is hard to do without assistance. Be careful not to button hole skin if you don't have an assistant.\\
Dr. Wong uses 10 blade to excise through breast tissue.\\
Measures nipple placement. Usually about 11-13 cm from midline and 2-3 cm above IMF. Uses the eye test. Remember they are more lateral than female nipples.\\
Dr. Wong has switched to closing with a 3-0 coviden v-lock purse string and a 4-0 monocryl subcuticular. Dressing is steri-strips and exofin glue. Leave a window to assess NAC viability.\\
Dr. Wong would like to see patient in PACU right before discharge to look for a hematoma.\\


Post-Operative Instructions:\\
- Okay to shower after 48 hours\\
- Okay to remove dressing except for drains and yellow bolster in 48 hours\\
- No lifting greater than 5 lbs\\
- Please call to confirm your follow up in 1 week\\
- No NSAIDs for 2 days\\

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==== Breast Revision ====
Suture: 3-0 vicryl for closing capsule or deep layer, 3-0 monocryl, 4-0 monocryl
Dressing: Dermabond, steristrip over tails, Bra

==== Breast Reduction ====

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Operative Report:\\
1. Superiomedial Pedicle Wise Pattern Breast Reduction\\

An identical procedure was performed on both sides. Surgical markings were done in the pre-operative holding bay to indicate a superomedial pedicle with Wise-pattern skin excision. The new nipple-areolar complex was marked using a 42 mm cookie cutter and excised in a partial thickness fashion. The surrounding skin overlying the pedicle was de-epithelialized with a scalpel. Skin overlying the remaining areas of excision were removed in a full-thickness fashion.
 
The superomedial pedicle was developed with Bovie electrocautery to the chest wall, making sure not to undercut the pedicle. The nipple-areolar complex at this time appeared healthy and viable. The superolateral skin flap was developed, maintaining a thickness of 2 cm with even contour compared to the contralateral side. This was carried down to the chest wall superiorly. We preserved the breast tissue at the inferomedial aspect in order to maintain medial fullness. The remaining lateral aspects of the breast were excised. The breast excision was then passed off as specimen (right side weighing 843g and left side weighing 855g). Some of the medial breast tissue was debulked to facilitate closure.
 
The this point the skin was temporarily stapled close and the patient raised to a seated position. On palpation and visual inspection, both sides appeared equivalent from a volume standpoint. We tailor tacked the T-incision to improve the contour bilaterally. The areas of excision were marked. The patient was returned to a supine position and the skin was excised sharply with a scalpel.
 
The staples were removed and the wound was irrigated thoroughly with normal saline. Adequate hemostasis was obtained. The superior pole was further dissected superiorly with Bovie electrocautery to accommodate the rotated pedicle as well as facilitate superior pole fullness. The skin was again stapled closed temporarily. Scarpa's layer was closed with 3-0 Vicryl suture and the inframammary fold was closed with running 3-0 V-Lok suture. The nipple-areolar complex and vertical limb were closed with buried deep dermal 3-0 Monocryl followed by running 4-0 Monocryl. The incisions were dressed with SteriStrips and Exofin glue. The patient was placed into a surgical bra with gauze fluffs.
 
On completion of the case, bilateral nipple-areolar complexes appeared healthy, well-perfused, and viable.
 
The anesthesia team then performed bilateral pectoralis blocks for post-operative analgesia. See their Procedure note for complete details. The patient was awaken from anesthesia and transferred to the PACU in good condition with no apparent complications.

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Photos\\

Tourniquet: finger / forearm / arm\\
Drain: Type of drain and placement\\
Sutures: List all layers\\
Dressing: What's preferred?\\

Anatomy: Pertinent anatomy should be listed\\

Post-operative care:\\
- Discharge home.\\
- Keep surgical bra on at all times except to shower.\\
- Okay to shower beginning POD 2.\\
- OTC analgesics for pain. Oxycodone as needed for breakthrough pain.\\
- Follow up in Plastic Surgery clinic for wound assessment.\\

Learning points/Pimp Questions:\\

Dr. Wong wants you to print out AP pre-operative photo and tape it up in the OR. Remember to take it down at the end of the case or you will be fired.\\

Pre-op Markings: sternal notch, breast meridian can use draped ruler over neck. IMF and then pitanguy point for nipple placement.\\
Uses tumesence 1mg epi in 1L NS. Inject about 300-400 ccs in each side with a spinal needle.\\
Once you de-ep your pedicle, go straight down to chest wall. Take medial triangle as skin only so they don't get a divot there.\\
The lateral triangular mastectomy flap should be about two centimeters thick.\\
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==== Panniculectomy ====

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Operative Report:\\
1. Panniculectomy\\
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The patient was transported to Operating Room #_ and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. No Foley catheter was placed.
 
The patient was marked in the pre-operative holding area, standing. The patient did not have any significant fascial defects/hernias that were noted on clinic or physical examination. The marks were reinforced with attending physician.
 
We began by making the inferior incision with a #10 blade, on the inferior abdominal fold, underneath the pannus, 6.5 cm above the central vaginal cleft. This was deepened and hemostasis was achieved with Bovie electrocautery. Additional hemostasis was achieved with surgical clips. The incision was deepened and undermined until the anterior rectus sheath/abdominal fascia was reached. The patient had multiple scars from previous operative interventions, and meticulous dissection was performed in order to avoid injury to the abdominal fascia. The tissue was then undermined through the length of the incision inferiorly and superiorly, including over the mons pubis. Care was taken to preserve the neurovascular bundles to the superior flap. Once adequate undermining had been performed, we used Kocher clamps to carefully bring the inferior dermal edge to the proposed superior incision. We then flexed the bed slightly, and ensured that there would be adequate re approximation without significant tension on the closure. We then marked the superior incision line and made this in a similar fashion, with a #10 blade, and deepened with Bovie electrocautery. Once the pannus was removed, this was then weighed and sent to pathology as specimen. Weight: _ kg, _ lbs. Hemostasis was then secured with Bovie electrocautery, the tissue was temporarily stapled and observed for symmetry and tension. There was good symmetry, and there was adequate re approximation without significant tension. Therefore, x2 15 Fr round drains were then placed on either end of the incision, and were secured in place with 3-0 Nylon Roman sandal sutures. The SFS was then sutured with 2-0 Vicryl simple interrupted sutures, and the skin was closed with 3-0 absorbable Covidien V-loc sutures. The patient's abdomen was then cleansed and dressed with Steri-strips and Exofin surgical glue.
 
The patient had a formal TAPP block, per anesthesiology team post-operatively. Please see separate documentation for details.
 
The abdomen was dressed post-operatively with ABD pads and an abdominal binder. 

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Photos\\

Drain: x2 15 Fr round drains on either side of the incision.\\
Sutures: Drain 3-0 nylon, SFS 2-0 vicryl sutures, skin 3-0 Coviden v-loc\\
\\
Dressing: Surgical glue with steri-strips, ABD pads, abdominal binder\\
\\
Anatomy: Know the 3 zones of perfusion to the abdomen and which are severed during a panniculectomy. (Zone 1 and 2 are severed and zone 3 is left. Zone 1 is the dominant perfusion of the abdomen).\\
The 6.5 cm above the vaginal cleft is left in place so that the urethra is not disturbed and pulled upwards.\\
\\
Post-operative care: 
Regional Block\\
Keep patient flexed in bed\\
She does send patients home the same day\\
Weight lifting restriction of 5 lbs\\
\\
Learning points/Pimp Questions:\\
  * Print pre-operative photos (usually just the AP is sufficient)
  * Mark in the pre-operative holding area, with a permanent marker (she prefers Sharpie), standing up. Include the sternal notch so that you can mark the midline, and mark the abdominal midline, xiphoid process, and over the vaginal cleft.
  * She prefers to have the weight of the panniculectomy in pounds, as well for the op report.

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==== Lower Extremity Propeller Flap ====

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Operative Report:\\
1. Peroneal perforator based propellar flap for lower extremity reconstruction\\
\\
The patient was transported to the Operating Room and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered - Ancef. The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed. Anti-embolic compression devices were placed on bilateral lower extremities prior to induction. Foley catheter was placed and removed at the end of the case.
 
The previous right lower extremity WoundVac had been removed prior to prep and the wound was carefully inspected. The area of the previously visualized arthrotomy appeared to be covered with healthy tissue. There were peroneal perforators that had doppler signal through the skin paddle that appeared to be an adequate distance for a good pivot point for a propeller flap. Therefore, the arms were not prepped into the field for a possible radial forearm flap. Right thigh was included in the prep for skin graft harvest.
 
Attention was first directed towards identifying the peroneal-based perforators, tracing out what we had previously marked. A template was used to ensure that we would have adequate tissue coverage and laxity after rotation. We then marked and made the posterior incision on the right calf first with a #15 blade down into the subcutaneous tissue. The dissection was carried out subfascially until the perforators that we identified to the skin paddle. These were carefully protected, and the surrounding tissue was then cleared until the vascular pedicle was completely isolated. The rotation of the flap was again checked. The marks on the skin were reinforced with a marker, and a suture was placed on the main pedicle. There appeared to be 2 perforators that could be safely included within the rotation flap to cover the soft tissue defect, without significant kinking or tension. The anterior skin incision was then marked, and a subfascial dissection was carried out from the anterior incision down to the pedicle. The remainder of the tissue was cleared, and after reconfirming the doppler signals in the skin paddle and adequate arc of rotation, the skin incisions were completed at the proximal aspect. The sural nerve and lesser saphenous vein were carefully preserved. Meticulous dissection and hemostasis was secured with Bovie electrocautery and surgical clips. Once the flap was completely released from its surrounding attachments, and islandized on the perforators, this was carefully rotated over the soft tissue defect, where the previous arthrotomy and exposed neurovascular structures were identified. The wound was copiously irrigated with 6L or normal saline, until this ran clear. There were no foreign bodies identified. The distal aspect of the flap was secured, and the flap was inset with 3-0 Vicryl deep dermal, simple interrupted sutures. The surrounding tissue at the donor site was undermined, and hemostasis was achieved. The surrounding tissue was advanced to cover all exposed neurovascular structures with 3-0 Vicryl deep dermal, simple interrupted sutures, without significant tension.
 
After the flap was inset, the doppler signal was again checked and was present. The flap had brisk, bright red bleeding at the most distal aspect, without significant venous congestion or edema. The areas of interest were adequately covered, and the surrounding tissue was found to be bright red, healthy, and a good recipient for a skin graft. The skin was harvested from the right thigh, with a 3-inch guard x 3, for a total area of 9 x 5 cm + 3 x 3 cm + 4 x 3.5 cm sites x 3, at 12/1,000 of an inch. This was subsequently meshed 1:1.5 and used to cover the donor site and the lateral aspects of the wound. The skin grafts were secured in to place with skin staples and dressed with Adaptic, and the skin was closed with staples. The skin was then cleansed, and an incisional WoundVac and black sponge was then placed over the skin grafts and connected to 125 mmHg medium, continuous suction.
 
The right thigh split thickness skin graft donor sites had 40 mL of 1:1 1% Lidocaine with Epinephrine and 0.25% Bupivacaine was infiltrated. These were then dressed with Tegaderms and Ace wrap with graduated compression.
 
A well-padded right lower extremity posterior leg splint was then applied with bulky Jones dressing and bias. A window was cut for inspection of the flap. The flap had a good doppler signal at the end of the case.
 
The patient was awoken from anesthesia and transferred to the PACU in good condition with no apparent complications.

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Photos\\
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Tourniquet: Thigh tourniquet optional\\
Drain: Type of drain and placement\\
Sutures: 3-0 vicryl deep dermal sutures to inset flap. Skin graft secured with staples. \\
Dressing: Adaptic over skin grafts. (No bolster as there is a flap). Donor site: tegaderm, ABD, ACE wrap.\\

Anatomy: Of note, propellar perforator flaps can come from the medial posterior tibial artery perforators or the lateral peroneal perforators. This is a favorite in-service question.\\

Post-operative care: \\
RLE splint and WoundVac to remain in place until POD #5\\
Bedrest x 5 days, no dangle, no ambulation until cleared by plastic surgery\\
Okay for Lovenox in the evening, if hemodynamically stable and WoundVac.\\
RLE elevation all the time, as tolerated\\
RLE WoundVac 125 mmHg, medium, continuous suction\\
Ancef x 24 hours post-operatively\\

Learning points/Pimp Questions:\\
  - Order relevant preoperative imaging (CTA, US, etc.)
  - Mark the patient in pre-op (doppler skin perforators and mark with a permanent marker; she likes Sharpie)
  - Make sure to prep in possible vein graft donor sites, in case you convert to a free flap, if option

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==== Thighplasty ==== 
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DESCRIPTION OF THE PROCEDURE:  The patient was marked in the pre-operative area with a planned incision from the medial knee through the medial thigh and curving up laterally along the inguinal crease. The anterior portion of the incision was determined utilizing a medial vector pull test to determine the likely amount of tissue to be resected. The patient was brought back to the operative suite and remained on his stretcher in a supine position with an arm board table attached to the stretcher. All bony prominences were padded, SCD boots were placed. The patient was then identified and a proper timeout was taken, which all present parties were in agreement. General anesthesia was administered by anesthesia. The patient was then prepped and draped in the usual sterile fashion. 

We began by infiltrating the bilateral marked operative area with 180 mL of tumescence into each thigh (tumescence consisting of 1L of normal saline mixed with 1 mL of 1:1000 epinephrine). The anterior thigh incisions were then made using a #10 blade. Dissection was then carried straight down toward the muscular fascia and care was taken to not undermine anteriorly. Once at the level of the fascia, we began to undermine the flap posteriorly. Great care was taken to preserve the greater saphenous vein. Branches of the greater saphenous vein were clipped and transected sharply. Once undermining was deemed adequate and equal bilaterally, we began to determine the resection area of the posterior incision by tailor-tacking. The posterior incision was determined by placing a Cocher clamp on the dermis of the anterior flap then transposing the undermined posterior skin anteriorly and marking this point. This marked point was joined with the anterior incision and then this area was excised. Once cut this area was then stapled to ensure that the incision would close. The resected amount of tissue on the left was 0.6204 kg and on the right 0.6946 kg. The posterior incision was completed in this fashion and the entire marked area closed temporarily with staples to ensure that the wound was without undue tension. 
            
We then removed the staples and obtained hemostasis utilizing electrocautery. The wounds were then copiously irrigated with normal saline solution. 15 Fr round JP drains were placed both proximally and distally anterior to the the incision on the bilateral thigh. The drains were secured in place with a 3-0 nylon suture and biopatch with a Tegaderm dressing over the top. The incision was then restapled and the superficial fascial system closed with a running 2-0 V-Loc suture deep. The deep dermis and skin was then reapproximated with 3-0 VLoc in a running subcuticular fashion. Rescue stitches were placed with a 3-0 monocryl suture. The incisions were then covered with 1 inch steristrips and then exofin skin glue placed on top of this. The patient was then placed in compression leggings with abdominal pads over the incisions. 

All counts were correct at the conclusion of the case. Dr. Wong was present for the entirety of the case.  The patient was then subsequently extubated and brought to the PACU in stable condition and was admitted to the hospital for 23 hour observation. 
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Photos:
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Tourniquet: None

Drains: 2x JP drains per leg - 1x at distal aspect of incision, 1x at superior aspect

Sutures: 3-0 drains, 2-0 v-loc SFS, 3-0 Vloc subcuticular, 3-0 monocryl rescue stitches

Dressing: 1 inch steri strips, Exofen glue, ABD pads, compression leggings 

Anatomy: Dissecting down to visualize and protect the Greater Saphenous vein; femoral triangle 

Post-operative care: Compression leggings at all times for 6 weeks, may shower after 48 hours (remove leggings and then replace)

Learning points/Pimp Questions: Greater Saphenous vein, markings

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==== Fibula Flap for Mandible Reconstruction====

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Operative Report:\\
1. Free fibula flap for mandible reconstruction\\
\\
A tracheostomy, vessel dissection and preparation of the mandible was performed by Dr. Glasgow. Please see his operative note for the technical details of his portion of the case.\\
\\
The distal and proximal portions of the fibula were palpated and marked and the entirety of the fibular was drawn to length along the lateral aspect of the right leg. A doppler was used to identify perforators should a skin paddle be needed. 6cm was measured from both the distal and proximal aspect of the fibula for the planned osteotomy sites and as to ensure that adequate bone length remained at both ends. A scalpel was used to make an incision the length between the two osteotomy sites. Dissection was started on the distal aspect of the fibula near were the perforators were found. Dissection was carried down and through the muscle fascia and then laterally looking for perforators. Two perforators were found and preserved. While palpating the fibula through the muscles of the lateral compartment the dissection was taken down to the fibula both distally and proximally. Care was taken to leave a small 2mm cuff of muscle on the fibula to preserve the periosteum. Dissection was taken around the fibula in a medial direction , removing muscle off the fibula, until the anterior compartment was entered. We transected the anterior crural septum. Care was taken to not injury the anterior tibial artery and neurovascular bundle. At this point the decision was made to perform the distal and proximal osteotomies to aid in dissection and exposure. The proximal and distal aspect that had been previously marked for the osteotomy sites were exposed by dissecting the periosteum off the bone circumferentially. Care was taken to not injure the pedicle. A narrow malleable was placed on the back side of the bone over the pedicle to protect the vessels. A bone saw was used to create both distal and proximal osteotomies. This freed the fibula and allowed for better visualization. Dissection continued through the muscle to the interosseous membrane which was carefully incised with sharp dissection. A doppler was used to identify the pedicle and its location. Once this was confirmed dissection continued around the pedicle into the deep posterior compartment. At this point the distal aspect of the pedicle was identified and ligated to free up the distal aspect of the fibula with the pedicle attached on the medial side. Dissection was then continued from the inferior to superior direction around the fibula , removing the surrounding muscle from the flap. The doppler was used continuously to ensure the location of the pedicle. All perforating vessels were clipped and ligated. One of the perforators for the skin paddle was coming from the soleus muscle and one from the septum. The skin paddle was approximately 6 cm x 3 cm. The perforator from the soleus muscle was ligated and the paddle was freed from the underlying fascia. Once the proximal aspect of the fibular was reached the pedicle was followed from the fibula proximally into the leg. The bifurcation of the posterior tibial vessels was clearly seen and identified. The peroneal vessels were circumferentially dissected and ligated freeing the entire fibula along with its vascular pedicle. Hemostasis was achieved in the leg incision. The flexor halicus longus was sutured to the interosseous membrane with 3-0 vicryl sutures. The peroneus longus and soleus muscle were then sutured together to close the muscle using 3-0 vicryl sutures. A 15 french blake drain was placed through a separate stab incision on the inferior aspect of the leg and secured with a 3-0 nylon. The incision was closed with 3-0 monocryl deep dermal sutures followed by a 3-0 v-lok suture. The incision was dressed with exofin glue followed by an island dressing.\\
\\ 
The presurgical planning bone template was secured to the fibula at the most distal end and the osteotomy and screw hole sites confirmed and scored with a bovie. Working proximally on the fibula the periosteum and surrounding tissue was elevated off the bone with great care taken to not damage the pedicle. This was taken all the way down to the point of the proximal osteotomy. The middle osteotomy sites were similarly cleared of surrounding tissues. The lingual end of the fibua was lengthened as the condyle from the mandible was removed in order to provide additional bone. The harvested skin paddle would not fit in the reconstruction and was removed. Screw holes were pre drilled for the fixation and reconstructive bar screws. Fixation screws were placed to keep the template on the bone. A bone saw was used to make the osteotomies with care taken to avoid injury to the pedicle. The fixation screws were then removed and the bone segments aligned to the reconstruction bar. Screws were then placed and the fibula fixed to the reconstructive bar. The proximal aspect of the fibula that was to be placed in the cranial fossa for mandibular articulation was filed smooth and round by the OMFS team with a pineapple bur. The flap and reconstructive bar was inset and found to be in an adequate position. \\
\\ 
Following inset, the peroneal pedicle was dissected out and cleaned under a microscope. The left facial artery and branches of the external and internal jugular veins, which had been dissected out by the OMFS team were in good position relative to the pedicle vessels. Once the vessels were cleaned and aligned a vein sizer was placed under the scope and a 4.0 size flow coupler was used to complete the anastomosis using a Synovis flow coupler device. A hemostat was then used to ensure the two rings of the flow coupler were securely closed. The second vein was also anastomosed in the same fashion using a 3.0 flow coupler. Next our attention was turned to the arterial anastomosis. Adequate flow was noted from the facial artery which was clamped with a Biover clamp. After cleaning the vessel the anastomosis was performed in a back to front fashion with interrupted 8.0 nylon sutures. Next an implantable Cook arterial doppler was placed around the flap side of the anastomosis by wrapping the two ends around the artery and then using small clips to secure it in place. The incision was irrigated and hemostasis was achieved with electrocautery. A 15 F blake drain was placed through a stab incision on the inferior and lateral portion of the patients neck. The sub-maindibular incision was closed with interrupted 3-0 vycril sutures followed by staples. Elastic bands were placed to place the patient in MMF by the OMFS team. The incisions were dressed bacitracin.\\

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Photos\\
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Tourniquet: Thigh (optional)\\
Drain: 15 round french in neck and donor site\\
Sutures: Donor - 3-0 vicryl for muscle, 3-0 monocryl deep dermal (few) and 3-0 v-lok. Neck 3-0 vicryl deep. Staples.\\
Dressing: Surgical glue and island dressing for leg. Baci for neck\\

Anatomy: \\
Prefers Michael Zenn book free fibula chapter.\\
Post-operative care:\\
POD#0: ASA suppository (300 mg), NPO **per mouth** (okay for tube feeds), Unasyn q8 for 72 hours, peridex, light teeth brushing, no objects in mouth, drain care, ICU status with q1 hour flaps, wean vent, CAM boot for walking (6 weeks)\\
POD#1: Q1 hour flap checks, ASA 81 daily, start lovenox daily\\
Order PT/OT, SLP for speaking valve, RT to discuss downsizing trach/decannulation, nutrition for tube feeds\\
POD#2-4: Space flap checks as appropriate\\
POD#7: Check with OMFS to see if patient can be taken out of elastics. Dr. Wong is usually okay with discharge at 1 week. Donor site drain can be removed. Check with Dr. Wong regarding neck drain -- watching for spit.\\
POD#14: Swallow test (MBSS) - if passes can have pureed diet.\\
\\
Discharge:\\
Patient will leave with NG/PEG for tube feeds.\\
Cut wires for flow coupler and cook doppler and tape with tegaderm. They will be pulled at clinic.\\
ASA 81 for 1 month. No lovenox necessary.\\


Attending Pearls (Learning points/Pimp Questions):\\
Will ask about CPN\\
Will ask about the compartment of the leg.\\
- Try TPA if arterial anastomosis clots off
- 5000U of heparin

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