=====Dr. Domeshek Introduction=====
* Undergraduate: Duke University, BSE, 2001-2005
* Medical School: Duke University School of Medicine, 2005-2010
* Resident, General Surgery: Barnes-Jewish Hospital/Washington University School of Medicine, 2010-2013
* Resident, Plastic Surgery: Barnes-Jewish Hospital/Washington University School of Medicine, 2013-2016
* Fellow, Plastic Surgery & Hand, Peripheral Nerve & Microsurgery: Barnes-Jewish Hospital/Washington University School of Medicine, 2016-2017
* Fellow, Plastic Surgery, Pediatric Plastic Surgery, Hospital for Sick Children, 2017-2018
[[https://drive.google.com/open?id=18UW1pxu92DJfNRkG-sEDY2iHSE33Ryvt|Dr. Domeshek Publications]]
General Tips:\\
\\
===== Operative Reports =====
==== Breast Reduction ====
The patient was marked preoperatively in the holding area in an upright standing position. Sternal notch was marked, followed by bilateral breast meridians and IMFs and chest midline. New nipple position was determined by transposition of the IMF onto the meridian of each breast. New notch to nipple distances were 21 cm bilaterally. XX cm limbs were designed emanating obliquely inferiorly from this point to create 2 limbs of an equilateral triangle and indicate what would become the vertical closure. These limbs were connected to the medial and lateral extents of the IMF markings.
Once the markings were in place, the patient was brought to the operating room and positioned supine on the operating room table, where general endotracheal anesthesia was successfully induced.
A surgical timeout confirming patient and procedure was performed. The patient's chest and breasts were prepped and draped in the usual sterile fashion using chloraprep.
Preoperative markings were confirmed on the table. A 38mm cookie cutter was used to mark the new NAC, placed on bilateral breasts with the same applied pressure. An inferior pedicle technique was to be utilized and the expected pedicles were marked on the skin, using an 8cm base centered on the midline of each breast.
A near identical surgical procedure was then performed on both breasts:
A lap sponge was placed around the base of the breast to create a tourniquet effect. Incision was made through epidermis and into but not through dermis around each pedicle and nipple-areola complex. The pedicles were then de-epithelialized using a 10 blade. Incision was then made through skin into subcutaneous tissues along all remaining surgical markings. The pedicle was then defined using electrocautery: Starting on the medial aspect of the pedicle, dissection was carried through the breast tissue to the level of the chest wall, avoiding undermining of the pedicle while doing so. Once the medial aspect was defined, the lateral aspect, then the superior aspect were as well, until the pedicle was freed circumferentially (except inferiorly) from surrounding breast tissue. Electrocautery was then used to develop skin flaps superiorly, laterally, and medially, frequently feeling the thickness of the skin flaps to ensure they were not overly thinned out in order to avoid compromising blood supply. Thickness of the skin flaps was also assessed right to left ensuring a similar amount of tissue was being preserved on each side.
The intervening tissues between the pedicle and elevated skin flaps were resected using cautery. All resected tissues were saved and sent to Pathology for routine histologic examination. Careful attention was paid to hemostasis throughout the procedure.
On multiple occasions, the patient was sat in an upright sitting position to assess for size, shape, and symmetry of the breasts. At the completion of reduction, when similar appearance was noted between the right and left breasts, a total of XX g of tissue were resected from the right breast, and XX g from the left.
The patient was returned to the supine position, and copious irrigation was performed and hemostasis confirmed. A 15 Fr round blake drain was placed in each breast, exiting inferolateral to the IMF incision.
The breast skin was then stapled into anticipated closure pattern and the designed NAC region on each breast was excised using a scalpel. The nipple was then delivered through this created defect and sutured in place with 4-0 monocryl deep dermal stitches.
A layered closure of both breasts was performed consisting of interrupted 3-0 Monocryl buried deep dermal sutures followed by a running 4-0 Monocryl subcuticular suture along the IMF incision as well as the vertical closure limb. Around the NAC, closure consisted of 4-0 Monocryl deep dermal sutures followed by a running subcuticular 5-0 Monocryl stitch.
The closures were covered by Prineo tape.
The patient tolerated this procedure without complication, and awoke from anesthesia without incident. A surgical bra and abd pads were placed as dressings.
Drain: Case-dependent\\
Sutures: 3-0 monocryl, 4-0 monocryl for incisions; 4-0 (deep dermal) and 5-0 (subcuticular) monocryl for nipple; 4-0 nylon for drain stitch if applicable; 3-0 fast for rescue stitches\\
Dressing: Prineo/dermabond along all incisions w/ diamond around nipples (do not cover entire nipple for cap refill checks postop), gauze/ABD and surgical bra\\
====Ganglion Cyst Excision====
The patient was brought back to the operating room and placed supine on the operating room table. After successful induction of anesthesia, a surgical timeout confirming patient and procedure was performed.
A nonsterile tourniquet was placed high up on the right arm and the arm was placed on a hand table. After prep and drape in the usual sterile fashion using chloraprep, the lesion was palpated and noted to be just proximal to the flexion crease at the base of the ring finger. A transverse incision was designed overlying the lesion, just proximal to the crease. 0.25% marcaine plain was injected at the base of the digit.
The extremity was exsanguinated with the use of an esmarch and the tourniquet was inflated to 250 mmHg. Incision was made along the surgical marking into the subcutaneous tissue using a #15C blade. Once in the subcutaneous tissue, blunt dissection commenced using iris scissors and tenotomies. Once dissection had proceeded down to the surface of the cyst, blunt dissection was used to circumferentially free the lesion from surrounding tissue from attachments.
On its deep surface, the cyst was adherent to a small portion of the A2 pulley. The adherent section of pully, which was just a thin strip, was excised and removed in one piece along with the cyst. The flexor tendon was visualized and intact beneath this and the digit could be ranged without catching/triggering. The neurovascular bundles were identified and visualized on both the radial and ulnar aspects of the digit and noted to be intact and unscathed. The site was irrigated, the tourniquet deflated. All digits were well perfused on deflation of the tourniquet.
Hemostasis was confirmed, the site irrigated again, and then skin was closed with a combination of 4-0 Nylon horizontal mattress and simple interrupted stitches.
The site was dressed with ointment, adaptic, telfa, 4x4s, kling, webril, and a volar resting splint allowing flexion of digits distal to the MCPJ.
The patient tolerated all of this well and awoke from anesthesia without difficulty. The patient was brought in stable condition to the PACU.
Tourniquet: 100mmHg over patients SBP. She puts tape around the distal border of the tourniquet/webril to prevent prep from getting under tourniquet\\
Sutures: 4-0 nylon horizontal mattress\\
Dressing: Bacitracin ointment to incision, Adaptic, Telfa, 4x4s, kling wrap, webril, volar/dorsal resting splint (depends on cyst site)\\
==== Lip Laceration ====
She prefers 3-0 or 4-0 vicryl for the orbicularis muscle. This was a lip washout and then 4-0 or 5-0 preferred chromic for the wet part of the lip and 5-0 plain got for the dry part of the lip put a little Vaseline on that and make sure you do a very thorough wash out.
===== Nerve Transfers =====
The [[https://www.youtube.com/channel/UCAbKftrnMl2T0Nb_zVP3ADg|Wash-U Mackinnon Video Series]] is a MUST WATCH before doing a nerve transfer with Dr. Domeshek. She did fellowship with Mackinnon in 2016-2017.
==== Common Peroneal Nerve Release ====
Preop Dx: Right common peroneal neuropathy\\
Procedure: Right common peroneal nerve release at the fibular head\\
Findings: Compression of right common peroneal at fibular head\\
Drains: None\\
Operative Procedure:\\
The patient was brought back to the operating room and placed supine on the operating room table. After successful induction of anesthesia, a surgical timeout confirming patient and procedure was performed.\\
\\
A non-sterile tourniquet was applied to the right thigh. The right lower extremity was prepped and draped in the usual sterile fashion using chloraprep. The anticipated incision was marked with a surgical marker. The leg was exsanguinated with an esmarch and the tourniquet was inflated to 275 mmHg. 10cc of 0.5% marcaine with epinephrine was injected into the site.\\
\\
Incision was made through skin using a scalpel. Subcutaneous dissection was performed with the use of tenotomies, to the level of the superficial fascia covering the common peroneal nerve and the musculature of the lower leg. Through this layer, the common peroneal nerve and the leading edge of the peroneus longus, defined by the posterior crural intermuscular septum were identified. The overlying fascia was incised over these structures to better define them and determine the anticipated course of the common peroneal nerve moving anteriorly.\\
\\
The superficial fascia was then incised sharply with a scalpel moving from the region of the posterior crural intermuscular septum towards the anterior and innominate crural intermuscular septa.\\
\\
The posterior, anterior, and innominate crural intermuscular septa were then sequentially dissected free from surrounding musculature and released, taking care to avoid injury to underlying vasculature and nerve branches. \\
\\
On release of the posterior crural intermuscular septum, it was found to be quite tight and compressive on the peroneal nerve beneath. The septum was followed deep to the peroneus longus to ensure that no septal strands or tight fascia remained overlying the nerve.\\
\\
Attention was then turned to the common peroneal nerve proximal to its course beneath the peroneus longus. Neurolysis was performed to free it from fascia overlying it in this proximal course. In this dissection, the lateral sural nerve was examined for, but not encountered. Deep to the common peroneal nerve, the fascia overlying the surface of the soleus was also released to relieve chance of compression against this deeper structure.\\
\\
The course of the peroneal nerve was checked once more in the operative field to ensure that no further points of compression existed. None were appreciated and the tourniquet was deflated.\\
\\
Hemostasis was obtained and the site was irrigated.\\
Closure commenced with 3-0 monocryl deep dermal stitches followed by a running 4-0 subcuticular stitch and dermabond.\\
\\
The site was dressed with 4x4s, an abdominal pad, and an ace wrap from the toes to the knee.\\
\\
The patient awoke from anesthesia without difficulty and was transported in stable condition to the PACU\\
Must Watch: [[https://www.youtube.com/watch?v=PFhcchWfdKY|MacKinnon CPN Release]]
Drains: none\\
==== Medial head of triceps to Axillary Nerve ====
[[https://www.youtube.com/watch?v=HiMyb2fDfxA&list=PLCendnjQGUDrTppwajicxnbHzYqUveoqt&index=58&t=0s|Medial Triceps to Axillary Nerve Transfer - Standard (Feat. Dr. Mackinnon)]]
==== Spinal Accessory to Suprascapular ====
[[https://www.youtube.com/watch?v=QAHBRgXfyWA&list=PLCendnjQGUDrTppwajicxnbHzYqUveoqt&index=40&t=0s|Post. Approach - Spinal Accessory to Suprascapular Nerve Transfer - Standard (Feat. Dr. Mackinnon)]]
==== Double Fascicular ====
[[https://www.youtube.com/watch?v=nbLn7WWg0og&list=PLCendnjQGUDrTppwajicxnbHzYqUveoqt&index=14&t=0s|Double Fascicular video]]
====Triceps to Axillary Nerve Transfer====
The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.
The scapular spine and border was marked. A curvilinear incision was made over the posterior arm at shoulder, posterior to the deltoid. The deltoid and teres minor interval was identified, and there was a significant amount of scarring and adhesion along the axillary nerve. The sensory branch was identified and traced to the main superior and inferior branches, and these were circumferentially dissected free of the scar and neurolysed.
Nerve stimulation demonstrated no firing of the superior or inferior branch, and we therefore proceeded with the nerve transfer.
The interval between the triceps was identified, and the radial nerve found. The medial most branch was excluded and protected with a vessel loop. Nerve stimulation demonstrated isolated triceps stimulation without hand or forearm extensor function. The branch was traced into the muscle to gather sufficient length. It was distally transected and brought superiorly.
Using the microscope, the axillary nerve was tripped of the surrounding soft tissue scarring and adhesions, and cut back to healthy appearing fascicles. An end to end coaptation between the radial branch and recipient axillary branch was performed with 9-0 nylon and the microscope. Fibrin glue was placed over the coaptation.
The deep muscular layers were then re approximated with 2-0 and 3-0 pds. The skin flaps were then closed with 3-0 and 4-0 monocryl and dermabond. A bulky dressing was applied.
He was then transferred to the stretcher and returned to supine position. The patient was awoken from anesthesia and transported to recovery in stable condition.
Tourniquet: No\\
Drain: No\\
Sutures: 9-0 nylon, 3-0 and 4.0 monocryl and dermabond\\
Dressing: bulky dressing\\