Plastics

First, 10 mL of 1% lidocaine with epinephrine was infiltrated into the planned hairline/coronal incision. After allowing adequate time for vasoconstriction, a 15 blade was used to make an incision extending from the anterior aspect of the left auricle to the anterior aspect of the right auricle. Dissection was carried out through subcutaneous tissue to the level of the subgaleal plane posteriorly using electrocautery. The coronal flap was then elevated within the subgaleal plane paying careful attention to stay deep to the superficial layer of the deep temporal fascia. The frontal nerves were visualized, retracted and protected. At that point the frontal bone prominence was visualized. The dissection was transitioned to a subperiosteal plane, and dissection proceeded inferiorly to the supraorbital rims. The supraorbital foramens were identified and the neurovascular bundles going through them were preserved during the case. Of note, both neurovascular bundles were within a bony tunnel and had to be released by removing the inferior piece of bone using an osteotome. At that point, transillumination was used to outline the frontal sinus. A reciprocating saw was then used to remove the anterior table of the frontal sinus in a full thickness fashion. This was delivered without any injury to the posterior table or nasal frontal outflow tracts. Of note, the mucosa along the nasal frontal outflow tracts was preserved bilaterally. The bone was then contoured in the back table with a pineapple bur until the flattened appearance had been achieved. Additional contouring of the frontal bandeau was performed with a pineapple bur. Once the central portion of the frontal bone osteotomy had been contoured appropriately, this was stabilized to the frontal bone with three 4 mm plates using 4 mm self drill screws. Remaining contouring of the frontal bandeau as well as the supraorbital rims was performed with a pineapple bur. Once appropriate contour had been achieved, the frontal bone was copiously irrigated with antibiotic saline solution.    At that point, it was clear that the radix and dorsum of the nose needed augmentation. Therefore, we decided to harvest a sheet of deep temporal fascia 5 cm x 5 cm from the left side in order to be used with diced cartilage for the augmentation. The area was marked and the the fascia was harvested with electrocautery.   Next, we proceeded with the hairline advancement and the bilateral brow lift. The coronal flap was elevated posteriorly within the subgaleal plane all the way to the posterior scalp to allow forward advancement. Using electrocautery, several galeotomies every about 2 cm were then performed perpendicular to the plane of advancement. Care was taken not to go too superficial and compromise the vascularity of the skin. At that point we had enough advancement to decrease the forehead length to about 5.5 cm. Once we were satisfied with the advancement the skin edges were tailor tacked with staples, making sure to also advance the coronal flap superiorly at the lateral most extent of the lateral brow bilaterally in order to elevate the brows and correct as much of the preoperative brow ptosis as possible. Excess skin was appropriately excised from the anterior scalp flap, positioning the hairline forward and the brows in an ideal position. The wound was irrigated with antibiotic solution and hemostasis was obtained. A 7-French flat JP drain was placed into the posterior scalp and brought out through a separate stab incision. It was secured in place with a 3-0 Prolene suture. Next, a drill was used and bone tunnels were created within the anterior table just below the edge of the anterior scalp flap in order to allow anchoring of the scalp flap to the bone for a more durable result. Using a 2-0 PDS suture between the galea of the anterior scalp flap and the bone tunnel the flap was anchored to the bone at two different locations, one on each side. Next, the tissues were realigned and approximated in a layered fashion with interrupted 2-0 Vicryl sutures for the subgaleal plane, followed by a few interrupted 3-0 Monocryl sutures for the deep dermis and 3-0 Monocryl Stratafix suture for the subcuticular closure.

DVT PPX: SQH 5000
Intra-op abx: Ancef
Prep: ETT should be directed caudally. Rotate bed 180 degrees. Shave hair over incision marking (but not anterior sideburns). Betadine to face + ophthalmic betadine. Pull hair back with rubber bands. Sterile placement of corneal shields. Sterile injection of Lidocaine 1% w/ epi along bicoronal markings.
Sutures: Drain stitch (3-0 Prolen), brow lift (2-0 PDS), subgaleal closure (2-0 Vicryl), deep dermis (3-0 Mono), subcuticular (3-0 Mono Stratafix)
Drains: 1x JP drain exiting through incision
Relevant anatomy: facial nerve, temporoparietal fascia, supraorbital foramen, frontalis muscle, innervation/blood supply to scalp, nasofrontal ducts and frontal sinus, anterior/posterior tables of frontal sinus

Markings and Shaving:

Frontal sinus exposure:

Anterior table plating:

Dressing:

Our attention was directed to the mandibular angles. Approximately 5 mL of 1% lidocaine with epinephrine was infiltrated into the confines of the intraoral incisions. After allowing adequate time for hemostasis anesthesia, a 15 blade was used to make an incision along the right external oblique ridge. Dissection was carried out sharply with electrocautery until visualizing the mandible. A #9 periosteal elevator was used to elevate the periosteum and the masseter muscle from the posterior body and angle of the mandible. I was then able to visualize the prominent posterolateral aspect of the body as well as the mandibular angle. This was contoured carefully with a Sonopet iQ micro claw until appropriate contour had been achieved. I then directed my attention to the contralateral left side where a similar procedure was performed. A 15 blade was used to make an incision along the left external oblique ridge. Dissection was carried out sharply with electrocautery until visualizing the mandible. A #9 periosteal elevator was used to elevate the periosteum and the masseter muscle from the posterior body and angle of the mandible. I was then able to visualize the prominent posterolateral aspect of the body as well as the mandibular angle. This was contoured carefully with a Sonopet iQ micro claw until appropriate contour had been achieved. Both wounds were copiously irrigated with normal saline and hemostasis was confirmed. Symmetry was also confirmed. The incisions were then closed with 3-0 chromic gut suture in a running fashion at the myomucosal level.   Our attention was then turned to the chin to perform the genioplasty. The lower lip was stretched outward to allow visualization of the mental nerves through the mucosa and an incision was planned between the visible nerves. Approximately 5 mL of 1% lidocaine with epinephrine was infiltrated into the confines of the intraoral incision. A 15 blade was used to make an incision along the gingivobuccal sulcus. Electrocautery was then used to dissect through the mucosa and mentalis muscle leaving at least a 1-cm cuff of mucosa and muscle to allow easy closure after the procedure. Dissection continued with a periosteal elevator in a subperiosteal plane laterally on both sides to identify the mental foramen and neurovascular bundle, as well as inferiorly to expose the anterior surface of the chin. Great care was taken throughout the procedure to keep the mental nerves intact. We also ensured that some of the mentalis muscle remained attached to the anterior aspect of the mandible. The central and inferior aspects of the central mandible were very prominent and they were thus taken down conservatively with a pear bur. Then, we marked the location of the horizontal osteotomy, ensuring it was at least 5 mm below the apices of the canine teeth and 6 mm below both mental foramens. Then, two vertical osteotomy lines were designed perpendicular to the horizontal osteotomy line. In this case, the width of the central chin narrowing portion was determined to be 1.2 cm. The midline was also marked between the incisors to ensure proper alignment during plating. A reciprocating saw was used to complete the horizontal osteotomy and the two vertical osteotomies that resulted in removal of a central bone segment. The remaining two lateral bone segments were then brought to the midline and secured to the superior aspect of the remaining mandible with a 0.7 mm titanium X-plate using 12 mm screws. Another 0.5 mm titanium curve plate with 3 holes was used to secure the right lateral bone segment to the superior aspect of the mandible. The plate was contoured and secured in place using 10 mm screws. Also, a 0.5 mm titanium curve plate with 3 holes was used to secure the left lateral bone segment to the superior aspect of the mandible. The plate was contoured and secured in place using 10 mm screws. Good bone-to-bone contact was noted after plating was completed. We did not feel that anterior advancement or posterior setback of the chin was needed in this case. However, narrowing of the chin left a bony step on each side of the chin-mandible junction, and this discontinuity was eliminated and appropriately contoured using a Sonopet iQ micro claw. At that point we were satisfied with the result. The wound was copiously irrigated with normal saline and hemostasis was confirmed. Symmetry was also confirmed. The mentalis muscle was re-approximated with several interrupted 3-0 Vicryl sutures. The mucosal incision was then closed with 3-0 Chromic gut suture in a running fashion.

Prep: peridex-soaked throat packing
Sutures: intra-oral mucosa (3-0 Chromic gut), mentalis muscle re-approximation (3-0 Vicryl)
Dressing: None
Postoperative care: CLD x48h, liquid diet x48h, blended diet x4wks; peridex qid, abx x7d, avoid strenuous activity for 4 weeks
Relevant anatomy: mental nerve/foramen, masseter, mentalis; mandibular incision needs to be made 6mm below the mental nerve

Our attention was then directed to the nasal region. After appropriate markings were completed, the nose was injected with 1% lidocaine with epinephrine for a total of 8 mL. The nasal vestibule was packed with Afrin-soaked cottonoids. After allowing adequate time for vasoconstriction, bilateral marginal incisions were created and connected to a curved inverted-V transcolumellar incision. The soft tissues were elevated off the cartilaginous framework. This dissection proceeded along the nasal dorsum and nasal pyramid until arriving cephalad to the nasal radix. The dissection was also extended laterally to the piriform rim bilaterally. At this point, I had complete visibility of the lower lateral cartilages, upper lateral cartilages and the nasal bone. The medial crura of the lower lateral cartilages were flaring partially and the lower lateral cartilages had abnormal shape. No dorsal reduction was needed, but augmentation of the dorsum and radix was felt necessary. The Afrin-soaked cottonoids were removed and accounted for. The anterior septal angle was identified and the mucoperichondrium was elevated off both sides of the nasal septum taking care to avoid any perforations. We did have a perforation on the right that was recognized and repaired with 4-0 Chromic sutures. This was followed by separation of components to access to cartilaginous dorsum. Both upper lateral cartilages were separated completely from the dorsal septum leaving the mucosa intact. The caudal aspect of the septum was slightly curved and thus resected down to the anterior nasal spine with scissors. Then, the septal cartilage was removed leaving 10 mm L-strut which was measured with callipers. A small amount of the caudal aspect of the vomer bone was protruding into the right nostril, thus it was carefully removed to relieve some of the nasal obstruction. Lateral osteotomies were performed next to address the open roof deformity and the wide nasal bones. These were done as low to low continuous osteotomies intranasally, taking care to preserve websters triangle bilaterally. A single guarded osteotome was placed at the piriform rim and a mallet was used to complete the osteotomy extending to the level of the medial canthus bilaterally. A 2 mm osteotome was then used percutaneously to extend the osteotomy to the nasal radix bilaterally. The nasal bones were then infractured to close the open roof deformity and narrow the overall nasal width. It was felt that a double-level osteotomy was needed bilaterally at that point given the persistent convexity of the lateral wall mostly on the right, and thus completed along the inferior border of the nasal bone parallel to the low-to-low osteotomy using a 2 mm osteotome percutaneously. Since the septal graft that was harvested was not long enough, I elected to use cadaveric costal cartilage for some of the grafts. A septal extension graft was then carved to the desired dimensions from the cadaveric costal cartilage and placed along the caudal aspect of the septum, and secured to it with several 5-0 PDS sutures in a horizontal mattress fashion, and was positioned 6 mm above the anterior septal angle. At that point it was felt that a left spreader graft was necessary to improve the patency of the internal nasal valve. Part of the cadaveric costal cartilage was used to fashion the thin spreader graft for the left side. The spreader graft was then placed along the dorsal aspect of the L-strut and secured to the septum with several 5-0 PDS sutures in a horizontal mattress fashion. The dorsum was then closed by approximating the upper lateral cartilages over the dorsal septum with a few interrupted 5-0 PDS sutures. Our attention was then turned to the augmentation of the radix and dorsum using diced cartilage from the cadaveric costal cartilage and the already harvested deep temporal fascia. The cartilage was diced to 0.5 mm cubes and then placed in fascia which was sutured together with 4–0 plain catgut. The construct was “made to measure” on the back table and guided into the dorsal pocket using percutaneous 4-0 Chromic sutures on the cephalad aspect. A small amount of excess cartilage was milked out at the caudal end and then the graft was closed using 4–0 plain catgut, and secured to the cartilaginous dorsum using 5-0 PDS sutures. Our attention was then turned to the nasal tip that had to be restored since most of the ligamentous attachments were released due to the open nature of the rhinoplasty. We ensured that the lower lateral cartilages were completely freed from the underlying mucosa to the medial crus on both the right and left sides to allow caudal displacement and achieve a good nasal shape.  The low lower cartilage was then infiltrated with 0.5 mL of 1% lidocaine with epinephrine, and a cephalic trim preserving 6 mm of lower lateral cartilage in width was performed bilaterally. The septal extension graft was not extending all the way to the columella and the medial crura of the lower lateral cartilages were still somewhat curved so we decided to placed a columellar strut. It was carved to the desired dimensions from the cadaveric costal cartilage and placed in a subcutaneous pocket in the base of the columella without touching the anterior nasal spine. The columellar strut was secured in place between the middle and medial crura of the lower lateral cartilages with interrupted buried 5-0 PDS sutures. Transdomal sutures were then placed in the tip bilaterally to define the lower lateral cartilages. These were followed by caudal interdomal sutures to decrease the width of the tip. Then a domal equalization suture was placed on the cephalad aspect of the lower lateral cartilages to bring them together and restore symmetry. All tip sutures were completed with 5-0 PDS. At that point we had achieved appropriate nasal tip shape, projection, and support. Alar rim grafts were then carved to the desired dimensions from the previously harvested septal cartilage in order to support the patency of the external nasal valves. A subcutaneous pocket was created from cephalad to caudal paralleling the alar rim bilaterally. The alar rim graft was slipped into the pocket bilaterally. The cephalic end of the graft was trimmed to avoid palpability and distortion of the soft tissue facet. The wound was irrigated with normal saline solution, and hemostasis was confirmed. The skin was then closed with interrupted 5-0 Nylon sutures at the columella and interrupted 4-0 Chromic gut sutures intranasally. The soft triangles were not approximated with sutures but packed with bacitracin-soaked Surgicel sheet. At that point attention was turned to the alar bases. Alar flaring with anterior nostril show was obvious bilaterally requiring combined nostril sill excision and alar wedge excision. The area of resection was marked bilaterally prior to infiltrating 0.5 mL of 1% lidocaine with epinephrine. We designed the lower portion of the alar wedge excision around to the medial vertical wall of the nostril sill excision. Using the calipers we determined the sill width component and the height of the alar wedge component that was about 5 mm on the right and 6 mm on the left. We ensured symmetry between the two sides. Using a 15 blade the vertical sills were cut first followed by alar wedge incisions. Hemostasis was confirmed. The sill was approximated first with 4-0 Chromic sutures in a horizontal mattress fashion bilaterally. The alar incision was then approximated with interrupted 5-0 Nylon sutures on both sides.   All incisions were copiously irrigated with saline. The eyes were irrigated with balanced salt solution. Steristrips were then placed over the nasal dorsum after a proper skin preparation followed by a Denver nasal splint. Doyle splints lubricated with bacitracin ointment were also inserted in both nostrils and sutured together to compress the mucosal leaflets with a single horizontal mattress suture of 3–0 Prolene through the septum. Bacitracin was applied to the external nasal incisions followed by a drip pad. The hair was washed with shampoo and conditioner. The scalp incision was dressed with Bacitracin and Xeroform. A compressive dressing consisting of 4 x 8s and Kerlix were placed over the scalp. 　 　

Sutures: XX
Drains: None
Dressing: XX

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 2-3 cotton balls moistened in saline wrapped with xeroform (large sheet cut in half made into dumpling) and tegaderm. Dermabond 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: 2-3x saline moistened cotton balls, xeroform (cut large sheet in half)
Dermabond, ABD pads, vest

Have in OR:
-15F JP drain x 2
-2.2 cm cookie cutter
-Usually dc home from PACU
-Multiple surgical pens (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 with 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:

The patient was taken into the operating room, and placed supine on the operating room table. SCDs were placed onto the lower extremities for mechanical DVT prophylaxis. Intravenous antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis and re-dosed appropriately during the case. Following a smooth induction and atraumatic orotracheal intubation, a surgical time out was performed, and the patient's identification, site, and procedure were verified. The eyes were protected with scleral shields during the case. The craniofacial region was prepped and draped in the usual sterile fashion.

First, 15 mL of 1% lidocaine with epinephrine was infiltrated into the planned hairline/coronal incision. After allowing adequate time for vasoconstriction, a 15 blade was used to make a horizontal incision extending from the left auricle to the right auricle. Dissection was carried out through subcutaneous tissue to the level of the subgaleal plane using electrocautery. The coronal flap was then elevated within the subgaleal plane paying careful attention to stay superficial to the superficial layer of the deep temporal fascia. The frontal nerves were visualized, retracted and protected. Once the frontal bone prominence was visualized the dissection was transitioned to a subperiosteal plane, and dissection proceeded inferiorly to the supraorbital rims. The infraorbital foramens were identified and the neurovascular bundles going through them were preserved during the case. Transillumination was used to outline the frontal sinus. A reciprocating saw was then used to remove the anterior table of the frontal sinus in a full thickness fashion. This was delivered without any injury to the posterior table or nasal frontal outflow tracts. Of note, the mucosa along the nasal frontal outflow tracts was preserved bilaterally. The bone was then contoured in the back table with a pineapple bur until the flattened appearance had been achieved. Additional contouring of the frontal bandeau was performed with a pineapple bur. Once the central portion of the frontal bone osteotomy had been contoured appropriately, this was stabilized to the frontal bone with two 4 mm X plates using 4 mm self drill screws. Remaining contouring of the frontal bandeau as well as the supraorbital rims was performed with a pineapple bur. Once appropriate contour had been achieved, the frontal bone was copiously irrigated with antibiotic saline solution.

At that point we proceeded with the hairline advancement and bilateral brow lift. The coronal flap was elevated posteriorly within the subgaleal plane all the way to the posterior scalp to allow forward advancement. Using electrocautery, several galeotomies every about 2 cm were then performed perpendicular to the plane of advancement. Care was taken not to go too superficial and compromise the vascularity of the skin. At that point we had enough advancement to decrease the forehead length to 6 cm. Once we were satisfied with the advancement the skin edges were tailor tacked with staples, making sure to also advance the coronal flap superiorly at the lateral most extent of the lateral brow bilaterally in order to elevate the brows. Excess skin was appropriately excised in both directions, positioning the hairline forward and the lateral brows in an ideal position. Bleeders were appropriately electrocauterized and the tissues were closed in a layered fashion with interrupted 2-0 Vicryl sutures for the subgaleal plane, followed by a few interrupted 3-0 Monocryl sutures for the deep dermis. Subcuticular closure with a 4-0 Monocryl suture was completed for the central aspect of the hairline incision, and staples were used for the skin closure laterally. Prior to closure, a 7-French flat JP drain was placed into the posterior scalp and brought out through a separate stab incision. It was secured in place with a 3-0 Nylon suture

Photos

Tourniquet: N/A
Drain: 7 French flat JP
Sutures: 2-0 vicryl for subgaleal plane. 3-0 monocryl deep dermals. 4-0 monocryl subcuticular. Drain with 3-0 nylon suture
Dressing: Head Wrap Dressing

Anatomy: Scalp layers and when to transition to sub-periosteal plane, where facial nerve will be found, complications from damage to facial nerve, distance from hairline to brow in female

Post-operative care:
- Refer to Rhinoplasty ones
- Sinus precautions
- HOB elevated to 30 degrees
- Team takes down headwrap POD1, re-dress
- Typically continues abx in-house, okay for DVT ppx

Operative Report:
1. Left pedicled anterolateral thigh flap phalloplasty. 2. Formation of tubed pedicle flap. 3. Neurolysis of left dorsal clitoral nerve. 4. Coaptation of the left dorsal clitoral nerve to the left lateral femoral cutaneous nerve. 5. Partial closure of the thigh donor site with local tissue rearrangement, total surface area of 100 cm2. 6. Integra bilayer wound matrix dressing placement to left thigh wound (donor site) measuring 15 cm x 15 cm. 7. Coverage of left thigh Integra with a durable negative pressure wound therapy, total surface area of more than 50 cm2. 8. SPY indocyanine green fluorescence angiography to evaluate perfusion of the anterolateral thigh flap.

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. Heparin 5000 units was administered subcutaneously for chemical DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. All bony prominences and pressure points were well padded. After induction of general anesthesia, a timeout was performed with the entire team. The abdomen, perineum, and left thigh were prepped and draped in the usual sterile fashion. A Foley catheter was placed on the table in sterile fashion.   Our attention was first turned to the left thigh. A line was drawn from the anterior superior iliac spine to the lateral patella. The Doppler machine was used to identify the perforator vessels off of the descending branch of the lateral circumflex artery. Two strong perforators within the B region were dopplered out.  An skin paddle measuring about 17 cm x 17 cm was diagrammed and centered over the identified perforators. Using a 10 blade an incision was first made along the medial and superior borders of the skin paddle. First, the lateral femoral cutaneous nerve was identified superiorly on the fascia using blunt dissection and bipolar electrocautery, and traced proximally to gain adequate length for coaptation. Using electrocautery we dissected down to the fascia and the flap was harvested in a suprafascial plane from medial to lateral until the septum between the rectus femoris and vastus lateralis muscles was reached. The fascia was incised over the septum. Two perforators were identified and this corresponded to the perforators that we identified by Doppler before making incision. We identified the descending branch of the lateral femoral circumflex artery and vein in the septum. The selected superior perforator vessel was confirmed to branch off the descending branch of the lateral circumflex artery and vein, but the selected inferior perforator vessel was found to branch laterally and therefore not used. We carefully followed the selected perforator vessel down to the descending branch of the lateral circumflex artery and vein. We had to split a fair amount of vastus lateralis muscle and carefully dissected the perforators vessel away from the surrounding muscle. Small branching vessels were ligated between hemoclips. Once we had completed the dissection of the perforator vessels, we incised the lateral and inferior borders of the skin paddle and extended the incision down through the subcutaneous fat and deep fascia to identify the vastus lateralis muscle. We elevated the skin paddle in the subfascial plane to identify the already dissected perforators. At that point, examination of the skin flap demonstrated normal perfusion and skin edge bleeding. We then dissected the pedicle free of the surrounding connective tissue proximally towards its take-off from the femoral artery and vein to a point where there appeared to be sufficient length. 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 very thick and the proximal scarpal fat was thinned in situ. The flap was ready to be transferred to the recipient site. The SPY imaging device was brought into the field again 15 minutes later to ensure adequate venous drainage and complete drainage of the ICG was evident.   We then turned our attention to the recipient site at the mons pubis for preparation. A V-Y incision was made and the dissection was carried down to the fascia. A space for the neophallus was created by elevating flaps circumferentially. Through this incision dissection was carried caudal onto the dorsum of the clitoris where the left clitoral nerve was identified and neurolysis was performed. The nerve was prepared for coaptation. Of note the right clitoral nerve was left intact.   A tunnel was then created between the groin and the left thigh in the subcutaneous plane taking care not to injure the saphenous vein or the femoral vessels and lymph nodes. The rectus femoris muscle and the sartorius muscles were then elevated in order to allow passage of the flap from the donor to the recipient side. Only two perforating branches were clipped during the process. The tunnel was irrigated with normal saline and hemostasis was confirmed. The flap was then passed under the rectus femoris muscle and under the sartorius muscle and through the subcutaneous tunnel and delivered into the groin. Care was taken to confirm there was no kinking, tension, or compression on the pedicle. The left dorsal clitoral nerve was then coapted to the lateral femoral cutaneous nerve using interrupted 9-0 Nylon epineural sutures and the coaptation was reinforced with Tisseel glue. The anterolateral thigh flap was then tubed into a phallus, bringing the edges of the flap together with interrupted 4-0 PDS sutures. Its base was then secured to the mons with 3-0 PDS sutures in a horizontal mattress fashion. A 1/4 inch penrose was placed in the recipient site and secured with an interrupted 4-0 PDS suture. The distal tip of the phallus was then closed using a 3-0 PDS suture in a purse string fashion. Xeroform was applied to the opening.   Our attention was then turned to the closure of the donor defect. The thigh was irrigated and hemostasis was confirmed. The vastus lateralis muscle opening was approximated with 3-0 PDS sutures in a figure-of-eight fashion. Then, the vastus lateralis muscle and rectus femoris muscle were approximated with interrupted buried 3-0 PDS sutures. The skin and subcutaneous tissue of the defect was then undermined on all four sides for several centimeters, and the four corners were advanced towards the defect in a V-Y fashion and approximated using interrupted 2-0 Vicryl sutures for the fascial layer, interrupted 3-0 Monocryl sutures for the deep dermal layer and running 3-0 Monocryl Stratafix suture for the subcuticular closure. Dermabond was applied to these incisions. The remaining thigh wound was imbricated all the way around with a running 3-0 Monocryl Stratafix suture. The remaining defect measured only 15 cm x 15 cm and saw slightly deep therefore Integra bilayer wound matrix dressing was applied to the wound and secured to the skin circumferentially with staples. The Integra was then covered with a durable negative pressure wound therapy dressing that was connected to 125 mmHg continuous suction. No leaks were detected.   Examination of the flap demonstrated good capillary refill. The SPY imaging device was brought once again into the field and the patient received ICG as per manufacturer's guidelines. The flap perfused well and there was no clinical evidence of venous or arterial compromise. A Doppler signal was obtained on the flap and marked with a 5-0 Prolene stitch. Kerlix and tape was used to support the phallus flap in resting position. The SPY imaging device was brought into the field again 15 minutes later to ensure adequate venous drainage and complete drainage of the ICG was evident.    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. Of note, at the time of extubation and transfer to recovery there was strong doppler signal on the skin of the phallus.

Photos

Tourniquet: None
Drain: JP drains; Wound Vac
Sutures: 2-0 vicryl for fascial layers; 3-0 monocryl for deep dermals; 3-0 monocryl stratafix for skin
Dressing: Kerlix fluffs and tap to keep penis up and not dependent; vac to donor site

Anatomy: Review the Vaginal nerves; and ALT anatomy. Understand which nerves are going to be co-apted and which veins are taken with the ALT to maximize drainage. The ALT donor site is too big for direct closure and is closed with a skin graft.

Post-operative care:

• Bedrest for 48hours post op
• please keep phallus in neutral position on kerlix tower, replace kerlix PRN for soilage
• xeroform dressing placed in distal tip of phallus
• strict I's and O's
• foley in place until POD3

Attending Pearls (Learning points/Pimp Questions):
The tunnel needs to be wide as to not compress the flap.
Make sure you understand the coaptations for the nerves.
The surgery usually happens with a second stage to connect the neourethrea. A small opening will be made that needs to be flushes.
The tip can become congested.

Operative Report:

1. Liposuction abdomen, bilateral flanks, and back. 2. Bilateral hip/buttock augmentation with autologous fat grafting.

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 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.   Attention was first turned towards the abdomen and bilateral flanks. Tumescent solution was prepared by injecting a 2mL ampule of epinephrine with 1:1000 concentration and 25mL of 1% lidocaine. The solution was introduced via blunt tipped Byron trocars in the subcutaneous tissue of the abdomen and bilateral flanks through 2 stab incisions in the groin creases and 1 in the periumbilical region. A total of 1400 mL was given. Then, using the SAFE liposuction technique with a 5mm basket cannula, 1600 mL of lipoaspirate was removed of which 600 mL was clear fat.  At that point we were satisfied with the appearance and symmetry. All stab incisions were closed with interrupted 3-0 Monocryl sutures for the deep dermis and interrupted 5-0 fast-absorbing plain gut sutures for the skin. Dressings were applied including telfa and tegaderm. The drain site was dressed with a biopatch and tegaderms.   The patient was then turned into the prone position and the back, posterior flanks, buttocks, and thighs were prepped and draped in the usual sterile fashion. A stab incision was made in the superior gluteal cleft and mid back, as well as bilateral gluteal creases. The tumescent solution was introduced via blunt tipped Byron trocars in the subcutaneous tissue of the back and posterior flanks through these incisions. A total of 1500 mL was given. Then, using the SAFE liposuction technique with a 5mm basket cannula, 1400 mL of lipoaspirate was removed of which 60 mL was clear fat. Great care was also taken to avoid contour deformities by changing the angles and using crosshatching techniques.   The retrieved fat was collected sterilely into large cannister and decanted. It was then injected into the hips and some into the buttocks (mostly lateral buttocks) with an injection system using a 4 mm injection cannula. A total of 650 cc on the right buttock/hip and 600 cc on the left buttock/hip was then injected through the incisions in the superior gluteal cleft and bilateral inferior gluteal crease, with special care taken to inject in the subcutaneous plane above gluteus muscle and fascia. After adequate buttock and hip contour was achieved, the incisions were closed with interrupted 3-0 Monocryl sutures for the deep dermis and interrupted 5-0 fast-absorbing plain gut sutures for the skin. Dressings were applied including telfa and tegaderm. Foam pads were used to cover the areas of liposuction on the abdominal wall and back 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.

Photos Needs pre-op markings

Tourniquet: None
Drain: None
Sutures: 3-0 monocryl for deep dermals; 5-0 Fast for skin
Dressing: eye patch + Tegederm, make sure eye patch is in smiley-face position, foam pads circumferentially, Ab binder

Anatomy: danger zone

Post-operative care:
-Ambulate immediately.
-Sleep on stomach for 8 weeks
-Use special cushions previously purchased to avoid pressure when sitting
-No lifting greater than 5 pounds with the arms and no strenuous activity/exercise, for 4-6 weeks after surgery.
-Wear your post operative garment at all times (ok to remove to shower) for 8 weeks. There may be some additional foam padding placed in your garment. Please put this back in for the first few days if you take the binder off to shower for extra compression.

Attending Pearls (Learning points/Pimp Questions):

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):

Operative Report:
1. Penile inversion vaginoplasty (minimal depth), and perineoplasty.
2. Penectomy.
3. Scrotectomy.
4. Labiaplasty.
5. Clitoroplasty.
6. Adjacent tissue transfer, genital region (70 cm2).
7. Urethroplasty.
8. Bilateral orchiectomy.

INDICATIONS FOR PROCEDURE: This is a XX y.o. natal male affirmed female with gender dysphoria who presents today for minimal depth vaginoplasty. The WPATH guidelines have been followed and met. She has been living as a woman for over a year. She has been on hormones for over a year. She has 2 letters from independent mental health providers supporting her decision for gender affirming surgery. We reviewed the surgical technique and scar patterns for this procedure. She understands that this is not a reversible procedure. We also discussed the alternative of full depth vaginoplasty along with its benefits but she elected to proceed with minimal depth vaginoplasty. The risks were discussed at great length and include but are not limited to bleeding, infection, fluid collections (e.g., seroma, hematoma), delayed wound healing, skin necrosis, scarring including hypertrophic scar and keloid, numbness, loss of erogenous sensation, loss of sexual function, inability to orgasm, inability to have intercourse, pain with intercourse, necrosis of neoclitoris, chronic pain or sensitivity, injury to rectum/prostate/bladder, recto-vaginal fistula, neovaginal wall rupture, neovaginal prolapse, spraying of urine, injury or stenosis/stricture of the urethra, urinary tract infections, undesired or unacceptable cosmetic result, lower extremity neuropathy, need for further surgery, anesthesia related complications, stroke, heart attack, blood clot in the leg or lung, or death. We have talked about the need for a wound VAC dressing and potential need for a urinary catheter for more than 1 week. We reviewed the postoperative course along with expectations and restrictions. All her questions and concerns were addressed. Patient agreed to proceed with surgery and a consent form was signed.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and positioned supine on the operating room table. Sequential compression devices were placed on both lower extremities for DVT prophylaxis. Heparin 5,000 units was administered subcutaneously for chemical DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. After induction of general anesthesia, a timeout was performed with the entire team. The patient was placed in lithotomy in yellowfin stir-ups well padded. All bony prominences and pressure points were well padded. Markings were made. The abdomen, genitalia and perineum were prepped and draped in the usual sterile fashion. A 16 French Foley catheter was placed and the bladder drained.   
First, a 2 cm wide by 3 cm long rhomboid flap was designed in the perineum, with the ischial tuberosities and the tip at the perineal scrotal junction as landmarks for the base of the flap. The skin of the rhomboid flap was incised with a 10 blade, and using electrocautery the perineal flap composed of skin and fat was elevated down to the bulbar urethra. Then, the scrotal skin from the base of the penis to the perineo-scrotal junction was excised leaving the tunica vaginalis intact. The remaining tunica vaginalis was preserved to be incorporated into the soft tissue of the labia. Using a 15 blade, an incision was then made in the midline of the scrotum and along the ventral side of the penis. A circumferential incision in the penile shaft skin was also made 2 cm below the corona of the glans. This excess skin from the shaft will be used for the clitoral hood. A clamp was placed on the glans, and the penis was degloved in the plane of Buck’s fascia creating a flap that would be used to line the vulva and create labia minora. Care was taken not to injure the neurovascular bundle.    
We then proceeded with the bilateral orchiectomy. The tunica vaginalis was opened with electrocautery over the right testicle.  The right testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The right spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was also found to have a right inguinal hernia that I repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 2-0 Vicryl sutures in a figure-of-eight fashion. Then, a similar procedure was performed for the left testicle. The tunica vaginalis was opened with electrocautery over the left testicle.  The left testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The left spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was found to have a left  inguinal hernia that I repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 2-0 Vicryl sutures in a figure-of-eight fashion.  
The ischiocavernosus muscle and bulbospongiosus muscle were then dissected free from the corpora and bulb, and excised with electrocautery. Next, the urethra was elevated above the tunica albuginea of the corpora cavernosum and freed from the corpora cavernosum distally. Penectomy was then performed by opening the tunica albuginea on the ventral side directly adjacent to the urethral groove on the right and left exposing the corporal tissue. A Yankauer suction tip was used to dissect the entire corpora down to the ischium bilaterally. The corporal tissue was elevated off of the tunica with a freer elevator down to the ischium bilaterally. Care was taken to ligate the corporal vessel at the base bilaterally. The proximal base of the corpora were over sewn with a 3-0 PDS running locking suture bilaterally. Care was taken to preserve the neurovascular bundles at 10 o’clock and 2 o’clock.   
At that point, the bulb was reduced and it was plicated using 3-0 PDS sutures. The perineal portion of the vaginal canal creation was done.  The central tendon of the bulbar urethra was incised and the rectal sphincter was dropped posteriorly. The bulbar urethra was elevated away from the rectum up to the apex of the prostate.  At that point we were happy with the depth of the canal.   
Next, the urethra was amputated at the level of the adductor tendon. A vertical incision was made along the ventral aspect of urethra. The urethra was then opened and widely spatulated to the level of the bulb. The excess urethra was then used to line the vulva and the space between the neoclitoris and the urethral meatus.  The urethra was then everted and rosebuded from the 3 to 9 o'clock position with 4-0 PDS sutures.  
The clitoroplasty was then performed. The glans was split on the ventral surface through the urethra to splay open the glans. The central tip of the glans was excised and the remaining glans was thinned on the ventral surface using scissors. The 4 cm long and 1 cm wide remaining glans was then shaped into a clitoris. Horizontal mattress sutures (tunica-skin skin-tunica) were placed between the limbs half way down, bringing the limbs together. A second row of horizontal mattress sutures was placed in the clitoris to create a ridge. A cuff of penile shaft skin served as the clitoral hood.  
Using adjacent tissue transfer, the penile flap measuring 10 cm x 7 cm was then further undermined past the mons with electrocautery. The fat on the mons centrally over the symphysis was cleared with electrocautery. The tunica of the neurovascular bundle was pexied to the mons pubis with interrupted 3-0 Vicryl sutures so that the clitoris was at the level of the adductor. The limbs of the neoclitoris were sutured to the edges of the vulvar lining/urethral mucosa down to the inferior aspect of the urethral meatus with a running 4-0 Chromic suture bilaterally. The penile flap was then pulled down and into the canal. The rhomboid flap was sutured to the floor of the posterior vagina with interrupted 3-0 Vicryl sutures. The midline of the penile flap was then marked. An incision in the midline was made in the penile flap from the clitoral hood to the base of the urethral meatus. The penile skin flap was then sutured to the clitoral hood and lateral limbs of the neoclitoris all the way down to the urethral meatus with a running 4-0 Chromic suture bilaterally.  At that point the edges of the distal aspect of the inverted penile skin were approximated with interrupted 3-0 Vicryl sutures followed by a running 3-0 Monocryl suture. The inverted penile skin was then tagged down to the posterior prostate using Denoviellers using a 3-0 PDS suture to create the neovaginal canal that had minimal depth. We then tacked the skin of the canal to the surrounding tissue using 2-0 Vicryl sutures in a quilting fashion. Scrotal skin flaps were then elevated on both sides and used to create the labia majora. The remaining tunica vaginalis became the soft tissue of the labia. The tunica fat was tucked in and the outer edge of the labia majora was then closed with interrupted 3-0 Vicryl sutures for the deep dermis followed by a running subcuticular 3-0 Monocryl Stratafix suture bilaterally. The lateral aspect of the rhomboid flap was sutured to the penile skin flap laterally with interrupted 3-0 Vicryl sutures. Quilting sutures were then placed using 3-0 Monocryl to create more prominent labia minora.
The abdominal, genital and perineal skin was cleansed with normal saline. A wound vac with a black sponge covered with adaptic was placed on the vulva and perineum, and then connected to 125 mmHg of continuous suction without any detectable leaks. 
The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. Of note, the patient was repositioned from lithotomy every 3 hours, and positioning was rechecked each time. The bladder was intermittently drained. No hematuria was noted. All counts were correct at the end of the case. Dr. Higuchi's assistance was critical to the successful completion of this surgery because of the significantly increased complexity. No qualified residents were available to assist with this technically demanding operation.

Penile Inversion Vaginoplasty (Full Depth) Description Of The Procedure: The patient was taken to the operating room and positioned supine on the operating room table. Sequential compression devices were placed on both lower extremities for mechanical VTE prophylaxis. Heparin 5,000 units was administered subcutaneously for chemical VTE prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. After induction of general anesthesia, a timeout was performed with the entire team. The patient was placed in lithotomy in yellowfin stir-ups well padded. The arms were tucked. All bony prominences and pressure points were well padded. Markings were made. The abdomen, genitalia and perineum were prepped and draped in the usual sterile fashion. An 16 French Foley catheter was placed on the table in sterile fashion, and the bladder drained.    First, a 2 cm wide by 3 cm long rhomboid flap was designed in the perineum, with the ischial tuberosities and the tip at the perineal scrotal junction as landmarks for the base of the flap. The skin of the rhomboid flap was incised with a 10 blade, and using electrocautery the perineal flap composed of skin and fat was elevated down to the bulbar urethra. Then, the scrotal skin from the base of the penis to the perineo-scrotal junction was excised leaving the tunica vaginalis intact. The remaining tunica vaginalis became incorporated into the soft tissue of the labia later. The scrotal skin was kept on the back table to be used later for vaginal reconstruction. Using a 15 blade, an incision was then made in the midline of the scrotum and along the ventral side of the penis. A circumferential incision in the penile shaft skin was also made 2 cm below the corona of the glans. This excess skin from the shaft was later used for the clitoral hood. A clamp was placed on the glans, and the penis was degloved in the plane of Buck’s fascia creating a flap that would be used to line the vulva and create labia minora. Care was taken not to injure the neurovascular bundle.     We then proceeded with the bilateral orchiectomy. The tunica vaginalis was opened with electrocautery over the left testicle.  The right testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The right spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was found to have a right inguinal hernia that we repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 0 Prolene sutures in a figure-of-eight fashion. Then, a similar procedure was performed for the left testicle. The tunica vaginalis was opened with electrocautery over the left testicle.  The left testicle was delivered and held with a penetrating towel clamp.  The surrounding tunica vaginalis and the adventitia of the spermatic cord were dissected free up to the pubic symphysis and the external ring. The spermatic cord was skeletonized. The left spermatic cord, vas deferens, vein and artery were suture ligated with a 0-Silk suture. We ensured that the remaining tissue was hemostatic. Care was taken to be sure that the cord retracted back into the canal and was not palpable. She was found to have a left inguinal hernia that we repaired primarily. The hernia sac was separated from the cord and reduced below the fascia and the fascial defect was then approximated with several 0 Prolene sutures in a figure-of-eight fashion.   The ischiocavernosus muscle and bulbospongiosus muscle were then dissected free from the corpora and bulb, and excised with electrocautery. Next, the urethra was elevated above the tunica albuginea of the corpora cavernosum and freed from the corpora cavernosum distally. Penectomy was then performed. The tunica albuginea was incised on the ventral side on the right and left exposing the corporal tissue. A Yankauer suction tip was used to dissect the entire corpora down to the ischium bilaterally. The corporal tissue was elevated off of the tunica with a freer elevator down to the ischium bilaterally. Care was taken to ligate the corporal vessel at the base bilaterally. The proximal base of the corpora were over sewn with a 4-0 PDS running locking suture bilaterally. Care was taken to preserve the neurovascular bundles at 10 o’clock and 2 o’clock.    At that point, the bulb was reduced and it was plicated using 3-0 PDS sutures. The perineal portion of the vaginal canal creation was done.  The central tendon of the bulbar urethra was incised. The bulbar urethra was elevated away from the rectum up to the urogenital diaphragm.    Next, the urethra was amputated at the level of the adductor tendon. A vertical incision was made along the ventral aspect of urethra. The urethra was then opened and widely spatulated to the level of the bulb. The excess urethra was then used to line the vulva and the space between the neoclitoris and the urethral meatus.  The urethra was then everted and rosebuded from the 3 to 9 o'clock position with 4-0 PDS sutures.   The clitoroplasty was then performed. The glans was split on the ventral surface through the urethra to splay open the glans. The central tip of the glans was excised and the remaining glans was thinned on the ventral surface using scissors. The 4 cm long and 1 cm wide remaining glans was then shaped into a clitoris. Horizontal mattress sutures (tunica-skin skin-tunica) were placed between the limbs half way down, bringing the limbs together. A second row of horizontal mattress sutures was placed in the clitoris to create a ridge. A cuff of penile shaft skin served as the clitoral hood.   Using adjacent tissue transfer, the penile flap measuring 10 cm x 7 cm was then further undermined past the mons with electrocautery. The fat on the mons centrally over the symphysis was cleared with electrocautery. The tunica of the neurovascular bundle was pexied to the mons pubis with interrupted 3-0 Vicryl sutures so that the clitoris was at the level of the adductor. The limbs of the neoclitoris were sutured to the edges of the vulvar lining/urethral mucosa with interrupted 3-0 Vicryl sutures at the base and running 4-0 Chromic sutures on the sides. The rhomboid flap of the perineum was sutured to the floor of the posterior vagina with interrupted 3-0 Vicryl sutures.     Next robotic assistance was utilized to create the vaginal canal.  First, the robotic ports were placed and the abdomen was insufflated taking care not to injure the intraabdominal organs. Five robotic ports were placed, 1 in the central upper abdomen and 4 ports in a line with that.  The abdomen was inspected with the camera and no injuries were found. We opened the peritoneum right underneath the seminal vesicles. We identified the seminal vesicles and then identified the Denonvilliers fascia. We separated Denonvilliers fascia to develop a space underneath the prostate and between the prostate and rectum.  We worked our way towards the perineal incision while staying above the rectum.  We eventually were able to palpate the robotic instruments through the perineal area. We then connected the 2 incisions from the perineal area. After these incisions were connected, we started to widen the space robotically to be able to place 4 fingers into the vaginal canal.  A peritoneal flap (7 cm x 6 cm) from anterior rectum and posterior bladder were harvested for the colporrhaphy. The excess scrotal skin was then thinned and prepared as a full thickness skin graft 8 cm x 15 cm to line the vagina. It was sewn together over the 35 mm dilator first with interrupted 3-0 Vicryl sutures followed by a running 3-0 Monocryl suture. The graft was then sutured to the penile flap using two layers, first with interrupted 3-0 Vicryl sutures and then running 3-0 Monocryl suture. At that point, Acell MicroMatrix 1000 mg was applied as powder to all the wound surfaces to assist with healing. The penile flap with the incorporated skin graft was then pulled down towards the perineum and into the canal and delivered into the vaginal canal that had been dissected with robotic assistance. The skin tube was then delivered into the canal to be sutured to the peritoneal flaps. It was clear that the penile flap was too short and some of the skin graft would be part of the external genitalia. The midline of the penile flap / skin graft construct was then marked.  An incision in the midline was made in the construct from the clitoral hood to the base of the urethral meatus. The construct was then sutured to the clitoral hood and urethral mucosa with running 4-0 Chromic sutures.  Scrotal skin flaps were then elevated laterally bilaterally and used to create the labia majora. The majority of the scrotal skin was previously excised leaving the tunica vaginalis behind. The tunica became the soft tissue of the labia. Some of it had to be excised bilaterally. The rest tunica fat was tucked in and the outer edge of the labia majora was then approximated to the inner edge of the remaining scrotal skin on each side with interrupted 3-0 Vicryl sutures for the deep dermis followed by a running subcuticular 3-0 Monocryl Stratafix suture bilaterally. The lateral aspect of the rhomboid flap of the perineum was sutured to the penile skin flap laterally with interrupted 3-0 Vicryl sutures. There was some excess tissue along the central aspect of the neolabia majora bilaterally and that was tailor tacked with staples for our planned resection. Once satisfied with the appearance it was marked bilaterally, the staples were removed, and the skin was excised with scissors. Hemostasis was obtained. Both wounds were approximated with interrupted 3-0 Vicryl sutures for the deep dermis followed by a running subcuticular 3-0 Monocryl Stratafix suture. The labia minora were then further defined by using horizontal mattress 3-0 Monocryl sutures between the medial skin and the neovulva on both sides from the level of the neoclitoris all the way down to just above the urethral meatus. While doing that, robotic assisted laparoscopic abdominal colpopexy was performed to fix the vagina into the proper position between the bladder and rectum. The anterior portion of the neovagina was reapproximated to the anterior leaf of the Denonvilliers fascia using 3-0 V-Loc suture in a running manner. The posterior aspect of the neovagina was fixed to the peritoneal reflection overlying the rectum. After this was done, the anterior and posterior leaves of the peritoneal flap were reapproximated robotically using running 3-0 V-Loc suture for closure of the neovagina. The canal was packed with antibiotic soaked Kerlix packing. The apex of the neovagina was visualized laparoscopically to confirm that the packing went all the way up to the apex. The ports were removed and the port sites were then closed. The deep dermis was approximated with interrupted 3-0 Monocryl sutures and the skin was approximated with 4-0 Monocryl suture in a subcuticular manner for all the abdominal incisions.   The abdominal, genital and perineal skin was cleansed with normal saline. Dermabond was applied to the abdominal incisions. A wound vac was placed on the vulva and perineum over the Kerlix vaginal packing, and then connected to 125 mmHg of continuous suction without any detectable leaks.  The patient was extubated by Anesthesia, and taken to the recovery room in stable condition. Of note, the patient was repositioned from lithotomy every 3 hours, and positioning was rechecked each time. The bladder was intermittently drained. No hematuria was noted. All counts were correct at the end of the case. Both myself and Dr. Higuchi were present for all the critical portions of this procedure.  Dr.

Drain: Wound Vac cut into filleted J and wrapped with adaptic and Foley
Sutures: Drain stitches: 2-0 nylons
Dressing: Wound vacuum as above

Anatomy: Pertinent anatomy should be listed

Post-operative care:
- Vaginoplasty pathway - USE SURGICAL PATHWAYS AND VAGINOPLASTY SMART SET
- Restrictions: bedrest 48 hours, shuffle gait and no abduction more than 20 degrees; should not sit at home

Learning points/Pimp Questions:

Markings:

WV:

Operation Titles:
1. Immediate first stage reconstruction of the bilateral breasts with a tissue expander (Sientra Dermaspan LPP-FH14S –> Right SN 22D0572-19; Left SN 22D0572-20).
2. Bilateral inferiorly-based vascularized dermal flap local tissue rearrangement for lower pole and central coverage in breast reconstruction; right 18 cm x 12 cm and left 17 cm x 11 cm.
3. SPY Indocyanine green fluorescence angiography to evaluate the perfusion of the mastectomy flaps bilaterally. 4. Debridement of right mastectomy skin flap, total length 10 cm. 
Due to the additional extensive length of surgery required by this technique with the inferiorly-based vascularized dermal flap local tissue rearrangement over and above typical tissue expander reconstruction and in accordance with the recommendations from the American Association of Physician coding, a 22 modifier will be added to the tissue expander reconstruction in addition to the tissue expander reconstruction for bilateral, which would carry a 50 modifier.
Operative Report:
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. Heparin 5000 units was administered subcutaneously for chemical DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. All bony prominences were padded. After induction of general anesthesia, the chest area was prepped and draped in the usual sterile fashion.
  Please refer to Dr. Tevis' operative note for full details of the bilateral skin sparing mastectomies and right sentinel lymph node biopsy.
  At the time that I was called into the operating room, the mastectomies 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. The mastectomy skin flaps were of uniform thickness, appeared pink and viable. 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 except the lateral and medial vertical limbs of the right mastectomy flap that were trimmed back to healthy bleeding tissue. Based on the above assessment and the rest of the patient's criteria I felt that prepectoral placement of the tissue expanders was appropriate. Given the thickness of the upper mastectomy skin flaps I felt that there was no need for acellular dermal matrix but only use inferiorly-based vascularized dermal flaps.
  We began with the right side. We irrigated the breast pocket with half strength Betadine solution. An 18 x 12 cm inferiorly-based vascularized dermal flap was marked out based on the previously marked Wise pattern and this was deepithelialized. Hemostasis was achieved. The footprint of the breast and tissue expander were confirmed on the skin markings and on the pectoralis major muscle.  Based on the pocket's dimensions we selected a Sientra Dermaspan LPP-FH14S tissue expander with a 14 cm base diameter. The pocket was again irrigated with half strength Betadine and the skin was prepped with betadine.  Gloves were exchanged and the selected tissue expander was placed into the pocket. Prior to doing that the air was removed from the tissue expander, and it was filled with 250 cc of air. The tissue expander tabs were sutured to the chest wall with interrupted 2-0 Vicryl sutures, and we ensured that it was positioned along the lateral border of the breast and inferiorly along the inframammary fold. The already prepared inferiorly-based vascularized dermal flap was then rotated and draped over the tissue expander into position to give lateral, medial and central coverage, and it was inset all the way around it with interrupted 2-0 Vicryl sutures between the edges of the inferiorly-based vascularized dermal flap and the pectoralis major muscle. The dermal flap covered most of the tissue expander. The wound was irrigated with half strength Betadine solution again and hemostasis was obtained with electrocautery. We placed two 15-French round JP drains in the subcutaneous pocket and brought them through separate stab incisions in the lateral aspect of the inframammary fold. Both drains were secured in place with a 3-0 Nylon suture. Then, we reapproximated the mastectomy skin flaps using interrupted 3-0 Monocryl sutures for the deep dermal layer, followed by a running 4-0 Monocryl suture in the subcuticular layer for the vertical limb and running 3-0 Monocryl Stratafix suture in the subcuticular layer for the horizontal limb.
  We then turned my attention to the left breast and a similar procedure was performed. We irrigated the breast pocket with half strength Betadine solution. An 17 x 11 cm inferiorly-based vascularized dermal flap was marked out based on the previously marked Wise pattern and this was deepithelialized. Hemostasis was achieved. The footprint of the breast and tissue expander were confirmed on the skin markings and on the pectoralis major muscle.  Based on the pocket's dimensions we selected a Sientra Dermaspan LPP-FH14S tissue expander with a 14 cm base diameter. The pocket was again irrigated with half strength Betadine and the skin was prepped with betadine.  Gloves were exchanged and the selected tissue expander was placed into the pocket. Prior to doing that the air was removed from the tissue expander, and it was filled with 250 cc of air. The tissue expander tabs were sutured to the chest wall with interrupted 2-0 Vicryl sutures, and we ensured that it was positioned along the lateral border of the breast and inferiorly along the inframammary fold. The already prepared inferiorly-based vascularized dermal flap was then rotated and draped over the tissue expander into position to give lateral, medial and central coverage, and it was inset all the way around it with interrupted 2-0 Vicryl sutures between the edges of the inferiorly-based vascularized dermal flap and the pectoralis major muscle. The dermal flap covered most of the tissue expander. The wound was irrigated with half strength Betadine solution again and hemostasis was obtained with electrocautery. We placed two 15-French round JP drains in the subcutaneous pocket and brought them through separate stab incisions in the lateral aspect of the inframammary fold. Both drains were secured in place with a 3-0 Nylon suture. Then, we reapproximated the mastectomy skin flaps using interrupted 3-0 Monocryl sutures for the deep dermal layer, followed by a running 4-0 Monocryl suture in the subcuticular layer for the vertical limb and running 3-0 Monocryl Stratafix suture in the subcuticular layer for the horizontal limb.
  The chest area and breasts were cleansed with normal saline. Mastisol and Steristrips were applied to the incisions. Biopatches and Tegaderms were placed on the drains sites.  She was placed into a surgical bra with fluffs.  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 portion of my part of the procedure.

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