Plastics

OPERATIVE TITLES:
1. Left pedicled parascapular fasciocutaneous flap for coverage of left axillary and lateral chest wall defect.
2. Use of SPY indocyanine green fluorescence angiography to evaluate perfusion of the parascapular fasciocutaneous flap.
  
DRAINS:
1. 15-French round JP drain under back closure - donor site.
2. 15-French round JP drain under fasciocutaneous flap – recipient site.
  
DESCRIPTION OF THE PROCEDURE:
The patient was taken to the operating room, and placed supine on the operating room table. SCDs were placed onto the lower extremities for mechanical DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. After successful smooth induction of general anesthesia, a surgical time out was performed, and the patient's identification, site, and procedure were verified. We ensured that all pressure points were well padded. The chest and left axilla were prepped and draped in the usual sterile fashion.
 
The breast surgeon proceeded with wide local resection of the left axillary mass, as well as wide local resection of the right mastectomy flap local recurrence. Please refer to the separate operative note for full details.
 
When I was called into the operating room, the left axillary and lateral chest wall defect was measuring 16 cm x 5 cm and it was about 5 cm deep with exposed axillary contents and latissimus dorsi muscle at the base. The wound was ready for soft tissue coverage. I placed a moist lap pad over the wound and covered it with Ioban. At that point the drapes were removed and the patient was placed in a right lateral decubitus position with an axillary roll under the right axilla. We ensured that all pressure points were well padded. The Ioban covering the wound was removed and the left arm, left chest/axilla and shoulder, and left back were prepped and draped in the usual sterile fashion.
 
I placed a moist lap pad over the left axillary wound and I began harvesting the parascapular fasciocutaneous flap from the left back. With the arm adducted, the scapular borders were identified and marked. Using a sterile doppler device we identified the superficial circumflex scapular artery coming through the triangular space to the skin just lateral to the lateral scapular border. A 16 cm x 5 cm oblique skin paddle was designed along the lateral scapular border with the skin perforator located centrally within the planned skin paddle. The skin paddle ended well superior to the level of the 12th rib. We ensured that there was enough skin laxity to close the defect primarily after the flap harvest. The inferior aspect of the skin paddle incision was then made with a 10-blade. Using electrocautery we beveled slightly away from the skin and dissected down to the latissimus dorsi muscle fascia. The dissection proceeded cephalad. The skin and subcutaneous tissue was elevated off of the underlying latissimus dorsi muscle deep fascia to the superior edge of the muscle. The teres major muscle was then identified just cephalad to that and the skin and subcutaneous tissue was elevated off of the underlying teres major muscle fascia carefully to the superior edge of the muscle. Dissection allowed identification of the superficial circumflex scapular artery emerging from the triangular space. Once the vessels were exposed, the remaining superior skin incision was completed using a 10-blade. Then, using electrocautery we beveled slightly away from the skin and dissected down to the muscle fascia and dissection proceeded from superior to inferior. The horizontal branch of the superficial circumflex scapular artery was identified medially and it was divided between ligaclips. The teres minor muscle was exposed and the vessels were again observed at the inferior border of this muscle going into the triangular space. At that point the entire skin paddle was free and perfused by the vertical branch of the superficial circumflex scapular artery. Dissection of the vessels continue for a few centimeters towards the quadrangular space in order to allow for better flap mobility. Once we were satisfied with the mobilization of the flap a wide subcutaneous tunnel (~ 7 cm width) just above the latissimus dorsi muscle was created between the axillary defect and the harvest site. The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines.  The flap perfused well and there was no clinical evidence of venous or arterial compromise. The flap was transposed into the defect under the subcutaneous tunnel and covered the majority of the defect except the anterior aspect for about 4 cm that was anterior to the anterior axillary line. The portion was closed primarily in layers using interrupted 3-0 Vicryl sutures for the fascial layer, interrupted 3-0 Monocryl sutures for the deep dermal layer, and running subcuticular 4-0 Monocryl suture. The excess flap under the subcutaneous tunnel between the axillary defect and harvest site was then marked and excised using electrocautery taking care not to injure the perforator vessels. A 15-French round JP drain was placed at the axillary defect through separate stab incision anteriorly, and another 15-French round JP drain was placed at the back defect through separate stab incision inferiorly. Both drains was secured in place with a 3-0 Nylon suture. Both defects were irrigated with antibiotic saline solution and hemostasis was confirmed. The parascapular flap was then positioned into the axillary defect and was sitting comfortably without any tension to the pedicle. The flap was inset with interrupted 3-0 Monocryl sutures for the deep dermis and a running subcuticular 4-0 Monocryl suture.
 
We then turned our attention to the back defect. The skin edges were approximated in layers using interrupted 2-0 Vicryl sutures for the fascial layer, interrupted 3-0 Monocryl sutures for the deep dermal layer, and running subcuticular 3-0 Monocryl Stratafix suture.
 
The chest, axilla, and back skin were cleansed. The back and anterior chest incisions were dressed with Dermabond. Bacitracin and Xeroform was applied to the incision line around the parascapular flap. Biopatches and tegaderms were used for both drain sites. A special sling was provided to maintain the left shoulder in 20 degrees of abduction to avoid any pressure on the flap.

Sutures: Fascia 3-0 vicryl, Skin 3-0, 4-0 monocryl, Drain: 3-0 Nylon
Drains:
1. 15-French round JP drain under back closure - donor site.
2. 15-French round JP drain under fasciocutaneous flap – recipient site.
Dressing: Dermabond, baci/xeroform, biopatch & tegaderm

PREOPERATIVE DIAGNOSIS:
Complex infected sternal dehiscence with missing segment inferiorly.

PROCEDURES:
1. Bilateral pectoralis major flap and bilateral rectus abdominis flap reconstruction of deep sternal defect.
2. Complex secondary repair of sternotomy incision (28 cm length).
3. Placement of Prevena incision management system.

DRAINS: 19-French round JP drain below the muscle flaps inferiorly where there was a sternal gap.
19-French round JP drain in the subcutaneous tissue laterally, one on each side.

Risk:
I discussed the benefits and risks of chest wall reconstruction with the patient that include but are not limited to bleeding, infection, wound healing issues, fluid collection (seroma, hematoma, lymphocele), risk of injury to surrounding structures/organs/nerves/vessels, chronic pain, sensory deficits, motor weakness, partial or complete muscle flap loss, abnormal scarring (hypertrophic and keloid scarring), asymmetry, possible need for additional surgery, the risk of anesthesia, DVT/PE, MI, CVA and possible death.

DESCRIPTION OF OPERATION:
The patient was taken to the operating room, and placed supine on the operating room table. SCDs were placed onto the lower extremities for DVT prophylaxis. Antibiotics were given intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. After successful smooth induction of general anesthesia, a surgical time out was performed, and the patient's identification, site, and procedure were verified. The chest and abdomen were prepped and draped in the usual sterile fashion.

The Cardiac Surgery team proceeded with another washout and debridement of the wound along with plating of the superior aspect of the sternum. This will be dictated separately. Once plating was completed we took over for the soft tissue reconstruction. At that point the sternal wound overall looked to be quite clean, having undergone multiple debridements. Some early granulation tissue was noted on the surfaces, and there was no clear necrotic tissue. The bony edges appeared well approximated superiorly having undergone plating. Inferiorly, the bony edges were clean but still quite separated, leaving a large central space, which was in close proximity with the underlying organs.

Based on the unknown status of the internal mammary arteries, pectoralis major advancement flaps was felt to be required on both sides. This was carried out initially on the left by first undermining the subcutaneous plane above the muscle all the way to the clavicle, inferior intercostal margin, and out to the lateral insertion of the pectoralis major. Then undermining was carried out beneath the muscle in the subpectoral plane. Division of the muscle laterally was required, although it did not require a complete division of all elements, with some of the superiormost elements remaining intact. The humeral insertion was also preserved. Care was taken in the course of dissection to preserve the thoracoacromial pedicle. Advancement was confirmed to easily be able to cover the superior and middle portions of the wound, although it was anticipated that the inferiormost portion would still be difficult to address with pectoralis major alone, given that a turnover flap design could not be carried out. Accordingly, I felt that we should also add the rectus abdominis muscle to cover the lower portion of the defect. In order to keep the soft tissues as solidly apposed as possible, the upper portion of the rectus abdominis muscle was elevated from its posterior sheath to facilitate centralization of the pectoral muscle without resection of the humeral insertion, keeping this in continuity with the lowest portion of the pectoralis major in a bipedicle flap design, with the rectus abdominis muscle based on the deep inferior epigastric vessels. An incision was accordingly made along the lateral aspect of the anterior rectus sheath, and dissected sufficiently far down to free up the muscle. It was disinserted from its superiormost insertion and raised in a strip-like fashion as a bipedicle flap. Of note, the muscle on the left side was very thin and as a result was partially torn but it was more robust on the right side. Identical procedures were performed on the right side, and both flaps were advanced medially to ensure we could fill the dead space inferiorly. The wound was irrigated again thoroughly using 50,000 units of bacitracin in 1L of normal saline and hemostasis was achieved. Inset of the 4 muscles was carried out by approximating through the center, overlapping the muscle over the bony edges in order to cover the plates and fill the underlying space. The flaps were fixated in place with interrupted 0 Vicryl sutures. Interrupted Lembert sutures were then utilizing using 0 Vicryl sutures to further approximate the muscles and imbricate them in order to obliterate the deep pectoral space inferiorly. This was carried out over a 19-French round JP drain, which was brought out through a separate stab incision inferiorly. Then, 19-French round JP drains were also placed into the lateral portions of the wound on each side and brought out through separate stab incisions inferiorly. All drains were secured with 3-0 silk sutures. Appropriate coverage of the plates, filling of the space and solid soft tissue repair was evident.

Our attention was then turned to the large anterior skin and fatty tissue wound. The two sides could be advanced to contact it, despite a very large space between them, without seeming to produce excess tension. The skin edges were somewhat macerated and thus trimmed back to healthy bleeding tissue. Closure was carried out with interrupted 0 Vicryl sutures for the fascia. The skin was then approximated with interrupted 3-0 monocryl sutures for the deep dermis, followed by a running subcuticular 3-0 Stratafix monocryl suture. Drains were connected to bulb suction. A Prevena incision management system was then placed over the incision to assist with healing.

Sutures: Drain stitch 3-0 nylon x3, 0 vicryl pops (undyed) on CT1 drowned in a bowl of betadine for fascia, 3-0 monocryl deep dermal, 3-0 monocryl stratafix subcuticular.
Drains: 19-French round JP drain x3.
Irrigation: 50k baci in 1L
Dressing: Custom provena +/- ioban to pull over breasts like a bra. biopatch and tegaderm (sealed well) for drains. Abdominal binder at night to bind arms at night or when patient has waxing mental status.

Resident Notes:

1. Immediate first stage reconstruction of the bilateral breasts with tissue expanders (133S-MX-13-T) and Alloderm (8 x 16 cm).
2. Use of SPY indocyaine green fluorescence angiography.

Anesthesia:
General.

Drains:
15-French Blake drain x2 in right breast pocket.
15-French Blake drain x2 in left breast pocket.

Operative Procedure:

At the time that I was called into the operating room, the mastectomies and left sentinel lymph node biopsy had been completed. The chest was reprepped and redraped and a new clean set of instruments was used for our part. I proceeded with first stage tissue-expander reconstruction. I irrigated both breast pockets with triple antibiotic saline solution and hemostasis was confirmed. I then examined the mastectomy skin flaps. The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines in order to evaluate the viability of the breast flaps. The breast flaps perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise. However, subpectoral placement of the tissue expanders was felt to be necessary due to the thickness of the flaps on both sides.

I began with the left side. I elevated the pectoralis major muscle by incising its lateral border and inferior attachments to the ribs. Its inferomedial origin was also divided. The pectoralis minor muscle was left attached to the chest wall. The perforators were controlled with cautery and small clips. Hemostasis was confirmed again after irrigating the pocket with triple antibiotic saline solution. The inframammary fold as marked in the preoperative area was transposed onto the chest wall with a marking pen. A sheet of thick Alloderm measuring 8 x 16 cm, which had been prepared as per manufacturers guidelines was then placed into the wound without touching the skin edges. I anchored the inferior edge of the Alloderm along the transposed inframammary and lateral breast border with interrupted 2-0 Vicryl sutures. Some of the sutures along the inframammary fold also helped to tack the mastectomy skin to the chest wall. The pocket was irrigated one more time with triple antibiotic saline solution, and gloves were exchanged. I selected an Allergan 133S-MX-13-T expander (with a 13 cm BD). This was soaked in triple antibiotic saline solution and I removed all the air from it. The expander was positioned into the breast pocket such that the inferior aspect of the base plate was positioned along the inframammary fold. The suture tabs were sutured to the chest wall with 3-0 Vicryl sutures. I then secured the inferior edge of the pectoralis major muscle to the superior edge of the Alloderm with interrupted 2-0 Vicryl suture. The wound was irrigated with triple antibiotic saline solution again and hemostasis was obtained with electrocautery. I placed two 15 Fr Blake drains in the subcutaneous pocket and brought them through separate stab incisions in the lateral aspect of the inframammary fold. Both drains were secured with a 3-0 nylon suture. I used the Magna-Finder to locate the port on the tissue expander and filled the expander with 100 cc of sterile saline. I reapproximated the mastectomy skin flaps using interrupted 2-0 Vicryl sutures for the fascial layer, interrupted 3-0 Monocryl sutures for the deep dermal layer, followed by a running 4-0 Monocryl suture in the subcuticular layer.

Biopatches and tegaderms were placed on the drains and dermabond applied to the incisions. She was placed into a surgical bra with fluffs. The patient was extubated by Anesthesia, and taken to the recovery room in stable condition.

Drain: 15 french blake drains - two per side
Sutures: TE tabs - 3-0 vicryl
Alloderm stiches - 2-0 vicryl
Drain stitch - 3-0 nylon
Skin - 3-0, 4-0 monocryl
Dressing: Drain: biopatch and tegaderm
Skin: Dermabond, fluffs, Bra

Resident Notes:

Pre-Operative Diagnosis:
Bilateral symptomatic macromastia associated with neck and back pain, as well as erythema intertrigo.

Post-Operative Diagnosis:
Bilateral symptomatic macromastia associated with neck and back pain, as well as erythema intertrigo.

Drains:
None. (He does not typically use drains for his breast reductions)

Description of the operation:

The patient was taken to the operating room and positioned supine on the operating table. Sequential compression devices were placed on both lower extremities for DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. All bony prominences were padded. After induction of general anesthesia, a Foley catheter was placed, which was removed at the end of the case. The chest area was prepped and draped in the usual sterile fashion.

Attention was first turned to the right breast. The breast was placed under smooth uniform stretch and a 42 mm areolar cookie cutter was used to delineate a new areolar border. The breast was first infiltrated with 50 mL of tumescent solution with epinephrine, taking care to stay out of the pedicle. The rest of the markings were incised in a Wise pattern technique. The skin around the marked areola and along the superomedial pedicle but within the Wise pattern was de-epithelialized sharply after it was placed under stretch with an Esmarch bandage. The pedicle was first dissected with electrocautery, making efforts to preserve broadly-based parenchymal attachment to preserve vascularity and sensation. The parenchymal excision was carried out next, preserving thick upper breast flaps, with limited undermining of the upper flaps, and leaving a thin layer of fatty tissue above the pectoralis fascia. Parenchymal reduction was mostly done inferiorly and laterally. Care was taken to hollow out the lateral-most portion of the lateral upper breast flap and part of the adjacent subaxillary fat roll to decrease its prominence, though it could not be completely eliminated. This created a cone shaped breast. The superomedial pedicle was freed enough inferomedially to allow transposition of the nipple-areolar complex superiorly to reach the desired position.

Attention was then turned to the left breast and the same procedure was performed. The breast was placed under smooth uniform stretch and a 42 mm areolar cookie cutter was used to delineate a new areolar border. The breast was first infiltrated with 50 mL of tumescent solution with epinephrine, taking care to stay out of the pedicle. The rest of the markings were incised in a Wise pattern technique. The skin around the marked areola and along the superomedial pedicle but within the Wise pattern was de-epithelialized sharply after it was placed under stretch with an Esmarch bandage. The pedicle was first dissected with electrocautery, making efforts to preserve broadly-based parenchymal attachment to preserve vascularity and sensation. The parenchymal excision was carried out next, preserving thick upper breast flaps, with limited undermining of the upper flaps, and leaving a thin layer of fatty tissue above the pectoralis fascia. Parenchymal reduction was mostly done inferiorly and laterally. Care was taken to hollow out the lateral-most portion of the lateral upper breast flap and part of the adjacent subaxillary fat roll to decrease its prominence, though it could not be completely eliminated. This created a cone shaped breast. The superomedial pedicle was freed enough inferomedially to allow transposition of the nipple-areolar complex superiorly to reach the desired position.

At that point, both sides were compared for symmetry. Pedicles and flaps were compared and trimmed as needed to ensure uniformity and symmetry. Tissue specimens were then individually weighed for comparison, and sent to pathology for histologic examination. 441 grams of tissue was removed from the right breast and 460 grams from the left breast since the left breast was slightly larger preoperatively. Both breast pockets were then copiously irrigated with normal saline solution and inspected, and hemostasis was confirmed.

A temporary finding suture was placed at the 12 o'clock position of the pedicle. The central inset position of the vertical limb was determined to optimize shape and symmetry, and the upper breast flaps were secured at this point using 2-0 PDS sutures at the Scarpa's fascial level. In this case, a few parenchymal medializing sutures were beneficial laterally to assist in centralizing breast volume from the periphery, using interrupted 2-0 PDS sutures. Inset at the skin level was also carried out so as to medialize the lateral upper breast flaps substantially, thus reducing central tension and providing a better shape with good projection. A provisional closure was carried out with skin staples to assess shape and symmetry. The patient was then brought up to the seated position intraoperatively and inspected, and adjustments of the closure were made; good volume and shape symmetry was confirmed. The new nipple-areola complex positions were then placed visually and measured to ensure symmetry, using a 38 mm areolar cookie cutter. In this case, they were marked 4.5 cm from the IMF for a 6.5 cm nipple position. Attention was paid to avoid excessively high position, anticipating later relaxation of the lower pole. The patient was then returned to a supine position.

The areolar cutout was first deepithelialized, and release of the dermis and some parenchyma was carried out with electrocautery around the inferior periphery of the areolar cutout, lengthening the superomedial pedicle slightly in the process, to allow the areola to comfortably imbricate upwards into its new inset position. The nipple-areola pedicle was then exteriorized and parachuted back down to the surrounding tissues with interrupted 3-0 Monocryl sutures for the deep dermis followed by a running subcuticular 4-0 Monocryl. The vertical and horizontal limbs were then closed bilaterally with interrupted 3-0 Monocryl sutures for the deep dermis and running subcuticular 3-0 Monocryl Stratafix. Both nipple-areola complexes appeared pink and viable after closure was completed. Mastisol and steristrips were used for dressings bilaterally. She was then placed into a surgical bra with fluffs.

Tourniquet: Breast Tourniquet with Esmarch
Drain: No
Sutures: Yes
Dressing: Mastisol, steri-strips (lg & small), Fluffs, surgical bra

Dr. K usually does the Wise Pattern superomedial pedicle.
Things to make sure in OR:
-Tumescence on back table w syringes
-40cc of 1% lido w/ epi
-Esmarch
-Multiple marking pens, he’ll go through at least 2-3
-For prepping: Arms out in T & wrapped w/ kerlex. Prep umbo to chin. Blue towels, then ioban. Arm sleeves and then bottom & top sheet. Then side sheets. He likes the pouches for instruments, not the hard containers.

PROCEDURE:
Bilateral subcutaneous mastectomy with free nipple graft measuring 2.2 x 2.2 cm.

DRAINS:
15-French round Jackson Pratt drain in each breast.

DESCRIPTION OF THE PROCEDURE:
The patient was taken to the operating room, and placed supine on the operating room table. SCDs were placed onto the lower extremities for DVT prophylaxis. Ancef was administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. After successful smooth induction of general anesthesia, a surgical time out was performed, and the patient's identification, site, and procedure were verified. The chest and upper abdomen were prepped and draped in the usual sterile fashion.

We began by excising the nipple-areolar complex on the right and the left as full-thickness grafts (2.2 x 2.2 cm circle) and handed them off to the back table. I then turned my attention to the right side where the upper breast incision was made using the 10 blade. The dissection was carried down to the plane between the breast parenchyma and the subcutaneous fat using electrocautery. The dissection was then carried cephalad and laterally creating a superior mastectomy flap. Care was taken to dissect over the axillary tail and include all breast tissue in the specimen. The breast tissue was then elevated off of the pectoralis muscle taking care to preserve the overlying fascia. The superior mastectomy flap was pulled down and the ability to close primarily was then confirmed. An inferior incision was made. Again, the dissection was carried out inferiorly in the plane between the breast parenchyma and the subcutaneous tissue, creating an inferior flap. The breast tissue was dissected free and sent off to pathology for analysis. Care was taken to undermine the inferior flap beyond the inframammary fold to obliterate it. The cavity was copiously irrigated and hemostasis was confirmed. The incision was then reapproximated and this was repeated on the left side. The upper breast incision was made using the 10 blade. The dissection was carried down to the plane between the breast parenchyma and the subcutaneous fat using electrocautery. The dissection was then carried cephalad and laterally creating a superior mastectomy flap. Care was taken to dissect over the axillary tail and include all breast tissue in the specimen. The breast tissue was then elevated off of the pectoralis muscle taking care to preserve the overlying fascia. The superior mastectomy flap was pulled down and the ability to close primarily was then confirmed. An inferior incision was made. Again, the dissection was carried out inferiorly in the plane between the breast parenchyma and the subcutaneous tissue, creating an inferior flap. The breast tissue was dissected free and sent off to pathology for analysis. Care was taken to undermine the inferior flap beyond the inframammary fold to obliterate it. The cavity was copiously irrigated and hemostasis was confirmed. The incision was then approximated. The patient was brought up into the seated position to confirm symmetry as well as nipple position. The new nipple-areolar complex was placed 1 cm above the incision and 2 cm from the lateral pectoral border. The patient was brought back down into the supine position. A 15-French round Jackson Pratt drain was placed on both the right and the left and secured with 3.0 nylon suture. The incisions were approximated with a few three way 2-0 Vicryl sutures between the breast flaps and pectoralis major muscle to ensure that the incision will not migrate. The incisions were then further approximated with interrupted 3-0 Monocryl sutures for the deep dermis, followed by a running subcuticular 3-0 Monocryl Stratafix suture. A 2.2 x 2.2 cm circle on the superior mastectomy flap was then de-epithelialized on both the right and the left. The nipple-areolar complexes, which had been removed earlier as full-thickness skin grafts, were then thinned and placed back on the chest wall and sutured into place using half buried running 5-0 chromic suture. In addition, single interrupted 5-0 chromic sutures were placed at 3, 6, 9, and 12 o’clock around the nipple for quilting of the nipple-areolar complex and better definition of the nipple. A bolster dressing was placed on the nipple-areolar complex grafts including cotton balls soaked in mineral oil wrapped with xeroform and secured with 3-0 Monocryl sutures and tegaderm. Mastisol and steristrips were used as dressings for the breast incisions. Biopatches and tegaderms were used as dressings for the JP drain sites. Foam was applied over the breasts and the patient was then placed in a chest compression vest.

Drain: 15F JP x2
Sutures: Yes
Dressing: Bolster dressing supplies: mineral oil, cotton balls, xeroform
Mastisol, steri strips (lg & small), Fluffs, foam surgical bra

Have in OR:
-15F JP drain x 2
-2.2 cm cookie cutter
-Usually dc home from PACU
-Multiple surgical pens (2-3)
-Large pieces of flat foam & surgical bra
-For prepping: Arms out in T & wrapped w/ kerlex. Prep umbo to chin. Blue towels, then ioban. Arm sleeves and then bottom & top sheet. Then side sheets. He likes the pouches for instruments, not the hard containers.

Procedure:
1. Bilateral breast augmentation, subfascial.
2. Autologous fat grafting to bilateral breast.

Description of Procedure:
The patient was taken to the operating room and positioned supine on the operating table. Sequential compression devices were placed on both lower extremities for mechanical VTE prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. All bony prominences and pressure points were well padded. After induction of general anesthesia, a timeout was performed with the entire team. The chest and abdominal/flank areas were prepped and draped in the usual sterile fashion.

  I placed Tegarderm sheets over the nipple-areola complex bilaterally. I began with the right breast. Using a 15 blade, I made a 6 cm incision just below the inframammary fold of the breast taking into account the nipple to fold distance and the asymmetry of the inframammary folds. I beveled superiorly to protect the inframammary fold and extended this incision down through the subcutaneous tissues and the pectoralis major fascia to the pectoralis major muscle. Using electrocautery and a lighted retractor I dissected in the plane between the pectoralis major fascia and the pectoralis major muscle to create a subfascial pocket, which would accommodate the implant. The pocket was irrigated with antibiotic solution and hemostasis was confirmed. A similar procedure was then performed on the left side. Using a 15 blade, I made a 6 cm incision just below the inframammary fold of the breast taking into account the nipple to fold distance and the asymmetry of the inframammary folds. I beveled superiorly to protect the inframammary fold and extended this incision down through the subcutaneous tissues and the pectoralis major fascia to the pectoralis major muscle. Using electrocautery and a lighted retractor I dissected in the plane between the pectoralis major fascia and the pectoralis major muscle to create a subfascial pocket, which would accommodate the implant. The pocket was irrigated with antibiotic solution and hemostasis was confirmed. At that point, implant sizers were placed into the subfascial pockets to guide selection of the permanent implants and assess for symmetry. Blunt dissection and electrocautery was used to optimize the shape of the implant pocket. The patient was brought up into the seated position to confirm symmetry and allow appropriate selection of permanent implants. Two Mentor Moderate Plus Profile Xtra 465 cc smooth round silicone permanent implants were selected. Good volume and shape symmetry was confirmed. Given the suboptimal upper breast tissue thickness and subfascial placement of the implants it was felt that autologous fat grafting to the upper pole of the breast bilaterally was necessary to enhance the tissue thickness and camouflage the implant edges. Also, there were minor volumetric asymmetries between the two sides with the left being slightly smaller that could also be addressed with autologous fat grafting.

  Her abdominal and flank donor sites for the fat grafting that were marked in the preoperative area were infiltrated with a blunt tipped cannula with tumescence solution through 3 small abdominal incisions. A total of 1500 cc of tumescence solution was used. After waiting a suitable period of time we began lipoaspiration using a 3.7 mm cannula.  Great care was taken to avoid very superficial suction and to avoid contour deformities.  The fat was collected sterilely from the upper and lower abdomen, as well as bilateral flanks.  The Revolve system was utilized for fat harvesting in the closed system. We then placed the fat in sterile 10 cc syringes for injection. All stab incisions were closed with a single deep dermal 3-0 Monocryl suture followed by interrupted 5-0 fast-absorbing plain gut sutures.

  Our attention was then turned to the breasts for fat grafting to the superomedial aspects of both breasts that were marked when the patient was in the seated position in the operating room after the sizers were placed. Some fat grafting was also used on the left side to enhance the breast parenchyma volume. Two small stab incisions were made on each breast to allow insertion of the fat grafting cannula. A total of 160 cc of autologous fat was grafted as per Coleman technique in layers on the left. The same procedure was perfomed on the right breast and a total of 100 cc of autologous fat was grafted.

  Subsequently, the implant sizers were removed bilaterally and replaced with permanent silicone implants. Both breast pockets were irrigated with antibiotic solution and hemostasis was confirmed. The skin was cleansed with Betadine. The two implants that were previously selected were opened and then soaked in antibiotic solution. The surgical gloves were changed, and the implants were placed into the breast pockets and oriented appropriately. A Keller funnel and a minimal touch technique was utilized. Satisfied with the appearance of the implants in the breast pockets, we proceeded with closure of the breast pockets. Sutures were carefully placed to avoid injury to the silicone implant. First, we placed three 3-point fixation sutures using 2-0 Vicryl between the superficial fascia along the lower aspect of the inframammary fold incision, the superficial fascia along the upper aspect of the inframammary fold incision, and the deep fascial at the inframammary fold to reinforce the inframammary fold. We then closed the breast wound in layers using additional 3-0 Vicryl sutures for the superficial fascia layer, interrupted 3-0 Monocryl sutures for the deep dermal layer, and running 4-0 Monocryl suture for the subcuticular plane.

  The chest, breast, and abdominal skin were cleansed with normal saline. Steristrips were applied to the breast incisions. The fat grafting injection sites were also dressed with Steristrips. Dressing were applied to all stab incisions used for liposuction including Telfa and Tegaderm. She was placed into a surgical bra with fluffs. Foam pads were used to cover the areas of liposuction on the abdominal wall and secured in place with an abdominal binder. The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. All counts were correct at the end of the case. I was present for the entire procedure.

Drain: None
Sutures: 3-0 Vicryl SFS, 3-0 Mono deeps, 4-0 Mono running, 5-0 Plain single-interrupted for liposuction sites if fat grafting
Dressing: Mastisol, steri-strips, Telfa, Tegederm (lg &sm)
Fluffs, surgical bra, (foam & abdominal binder if fat grafting)

Procedure:
1. Panniculectomy.
2. Monsplasty.

Description of Procedure:
The patient was taken to the operating room and positioned supine on the operating table. Sequential compression devices were placed on both lower extremities for mechanical DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. All bony prominences and pressure points were padded. After induction of general anesthesia, a timeout was performed with the entire team. The abdomen and flanks were prepped and draped in the usual sterile fashion.

  Using a 10 blade, the lower abdominal incision was made through the skin and down through the deep dermis. Of note, we had to go fairly low on the mons area to capture most of the disease within the mons area although a few areas of scar on each side of the penis could not be included. The dissection was carried down to the abdominal wall fascia with bovie electrocautery. The SIEV and SIEA branches were all controlled with cautery and surgical clips. The abdominal skin and subcutaneous tissue were carefully elevated off of the abdominal wall to just below the umbilicus centrally with limited lateral undermining. Rectus abdominis perforators were controlled with cautery and surgical clips. Of note, there was some scarring just above the fascia centrally where the disease was located but it was not extending below the fascia. The patient was then placed into a slightly flexed position and the upper abdominal flap was advanced to the lower to determine the extent of skin resection. This was marked and the skin was excised with a 10 blade and bovie electrocautery. 1774 grams of tissue was removed and discarded. The disease along the abdomen and most of the disease within the mons area was excised. The wound was then irrigated with antibiotic saline solution and hemostasis was confirmed. Two 15 French round JP drains were placed and brought out through separate stab incisions at the inferolateral aspects of the abdominal incision. The drains were secured in place with a 3-0 Nylon suture. Monsplasty was then performed by elevating the residual mons and securing its superficial fascial system to the abdominal wall fascia with interrupted 2-0 Vicryl sutures all the way across. At that point, the incision was temporarily closed with staples using our vertical plum lines made in preoperative area as reference points. We ensured that the standing cutaneous deformities laterally were eliminated. We then closed the abdominal wound in layers with interrupted 2-0 Vicryl sutures for the Scarpa's fascia layer, interrupted 3-0 Monocryl sutures for the deep dermal layer, and running 3-0 Monocryl Stratafix suture for the subcuticular closure. The abdominal skin was cleansed with normal saline. A Prineo dressing was applied along the abdominal incision. The drain sites were dressed with biopatches and tegaderms. ABD pads were used to cover the abdominal incision and secured in place with an abdominal binder. 
 
The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. All counts were correct at the end of the case. I was present for the entire procedure.

Drain: 15F round JPx2
Sutures: 2-0 Vicryl SFS, 3-0 Mono deeps, 3-0 Mono Stratafix running, 3-0 Nylon for JP
Dressing: Prineo, Biopatch, Tegederm
ABDs, ab binder

Operative Report:
1. Exact name of Operative Procedure:

Only the operative report should go in this section in the left column.

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: Include restrictions, splints, etc…

Attending Pearls (Learning points/Pimp Questions):