Plastics

Patient was marked in standing position in pre op and then taken to OR for GETA. After SCD boots placed and antibiotics given, 60 cc of tumescence fluid injected into proposed areas of liposuction and excision. Prepped and draped in sterile fashion. 3.7 mm cannula used with SAL to tail of breast bilaterally for total of 50 cc lipoaspirate. Thereafter, a 10 blade scalpel used to excise a bilenticular area from the lateral aspects of the breasts and chest wall to improve contour. Bovie used to complete the excision and then undermining was undertaken superiorly and inferiorly. Care was taken to stay superficial to underlying nerves. Irrigation undertaken and hemostasis achieved. Wounds closed in layers with 3-0 vicryl for deep dermal sutures and then 4-0 monocryl for running subcuticular suture. Dermabond and op site dressings applied. An abdominal binder was placed.

Tourniquet: No
Drain: No
Sutures: 3-0 vicryl for deep dermal sutures and then 4-0 monocryl for running subcuticular suture Dressing: Dermabond and op site dressings applied

Patient was marked in the preanesthesia area and brought to the operative theater. After adequate GETA was undertaken, the patient was prepped and draped in sterile fashion. Appropriate DVT prevention interventions undertaken and perioperative antibiotics were provided.

She was positioned prone and appropriately padded. We injected local into her scar and knife and bovie were used to incise the scar. We hoped to excise some of the scar but were unable at the end due to tension. I bluntly dissected above the periosteum with bovie, malleable, and uterine dilators to accommodate the 8 x 18 cm implant. We then irrigated copiously with antibiotics and saline and then assured hemostasis. We soaked the implant in the same solution and then sucked out the air through the internal port. We placed 10 cc of methylene blue and injectable saline in the implant and then placed the implant without folds. We then accessed it through the skin and injected another 10 cc for a total of 20 cc. We then closed the skin in layers with 3-0 vicryl for deep sutures and 4-0 prolene in the skin. Scalp was cleansed and dried and bacitracin was applied.

Tourniquet: No
Drain: No
Sutures: 3-0 vicryl for deep sutures and 4-0 prolene Dressing:No

Pre/Post Procedure Diagnosis: Gender dysphoria

Procedure: 1. Forehead reduction/set back and contouring 2. Bilateral brow lift 3. Division corrugators 4. Anterior hairline advancement flap 20 x 4 cm 5. Bilateral mandibular angle and ramus reduction/contouring 6. 8 mm genioplasty setback

Surgeon: Brooke French, MD

Assistant: Jonathan Freedman, MD resident

Anesthesia: GETA

EBL: 100 cc

IVF: See op note

Specimen: None

DOS: 10/31/19

Complications: None

Condition: Patient is extubated and transferred to PACU in stable condition

I have discussed the risks, benefits, alternatives and the procedure itself, including, but not limited to, pain, infection, bleeding, injury to surrounding structures, need for reoperation, recurrence, scarring, persistence of symptoms and asymmetry. The patient understands the typical perioperative course with the need/potential for dissatisfaction with results. All questions have been answered to the best of my ability.

Patient was marked in the preanesthesia area and brought to the operative theater. After adequate GETA was undertaken, the patient was prepped and draped in sterile fashion. Appropriate DVT prevention interventions undertaken and perioperative antibiotics were provided.

VSP had been performed to increase operative safety, efficiency and speed. First performed a bicoronal incision, diving into the hairline past the temporal recession bilaterally. Scalp flaps were reflected above the periosteum, taking care to stay deep below the temporal branch of the facial nerve. 7 JP drain placed posteriorly. Anteriorly based pericranial flap elevated and ultimately lain atop the forehead reconstruction and sutured to native scalp periosteum posteriorly for vascularized support of frontal bone graft. Cutting guides used to mark out the proposed cuts and then sonopet used to remove and horizontally split the anterior table inside the pneumatized sinus. This was placed in modling and plating guide and secured with plates and screws in the inner table. 4 plates and screws used along the outer table to secure into new recessed position. Burr used to then take down the lower forehead to appropriate level by drill guides that were marked and stained with pen. We secured the brow into position and then made adjustments with the burr. Corrugators accessed through galea and divided, protecting branches of supratrochlear nerves. We then advanced the brow superiorly to elevate the brow, while advancing the hairline inferiorly, particularly at the temporal recession regions. Part of non-hair-bearing forehead was excised in this region bilaterally and the flaps were brought forward and stapled. We placed the drain, irrigated and assured hemostasis. Closed in layers. Local injected into chin and mandibular region bilaterally. Teeth had been brushed with peridex and throat pack placed. First the mandibular reduction undertaken with sonopet to 3 -4 mm bilaterally. Washout and closure undertaken. Then genioplasty performed with gingivobuccal sulcus incision and protection of bilateral mental nerves. Calipers used for measurement and sonopet and oscillating saw used to taper the cut. Freed and set back 8 mm with stair step Stryker plate and 8 mm screws. Interferences or step offs burred with sonopet. Closed in layers and OG used after throat pack out. Headwrap and jaw braw applied.

Needle, sponge and instrument counts were correct at the conclusion of the case. I was present and scrubbed throughout, performing or directing all key aspects of the case. There were no complications apparent. Patient was extubated and transferred to PACU in stable condition.