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Table of Contents
Introduction
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Operative Reports
F to M Mastectomy Double Incision with Free Nipple Grafting
Operative Report
The patient was marked pre-operatively standing up. He was brought to the operative room and placed supine on the table. General anesthesia was administered and the patient was intubated atraumatically. SCD's were placed on bilateral lower extremities and pressure points were padded appropriately. Time out was performed, confirming patient's name, medical record number, date of birth, procedure and laterality. We infiltrated each breast with 150ml of wetting solution. This was comprised of 1L normal saline + 1mg epinephrine 1:1000. The patient's chest was prepped and draped in a sterile manner. We began by marking out the nipple areolar complexes (NAC) with the 25mm cookie cutter, and removed them with a knife as a full thickness skin graft. These were placed in a saline gauze and put on a back table. We worked on bilateral breasts simultaneously. We made the superior incision with a ten blade and Bovie, and ensured the mastectomy skin flaps were about 1.5cm, all the way down to the pectoralis fascia. We then made the inferior incision with a knife and Bovie, down to chest wall, and dissected the breast tissue off the pectoralis fascia. We then removed the breast tissue and passed them off for Pathology. We ensured hemostasis with Bovie cautery and stapled the incisions closed. We then sat the patient up and placed our NAC locations at about the 4th intercostal space, about 1.5cm superior to the incisions, and about 11cm from midline. After marking out the NAC locations, we sat the patient back down and de-epithelialized them. We removed the staples and checked the wounds again for hemostasis. We then washed out the wounds with normal saline. We placed a 15Fr drain in each wound and secured them with 3.0 Nylon. We closed the transverse incisions with 2.0 PDS in a 3 point suture, then with Vicryl 3.0, and lastly with 3.0 Covidien V-lock. These incisions were dressed with Steristrips and Dermabond. The NAC's were defatted and fenestrated with a 15 blade. These were secured on the chest with 5.0 Chromic. Bolsters made out of cotton balls, mineral oil and Xeroform were placed over the NAC grafts and tied over with 3.0 Silk. These were then covered with Tegaderms. The drains were dressed with Biopatches and Tegaderms. We then requested bilateral PECS blocks by Anesthesia, to assist in postoperative pain (please see their note for details). He was then placed in a compression vest and fluffs.
Drains: 2x 15 french Blake drains, 1 on each side
Dressing: Prineo, bolster, cover everything in telfa tegaderm, biopatch and tegaderm for the drain. Bolster is cotton balls, mineral oil and xeroform.
Sutures: 2-0 PDS 3 point stitch. 3-0 nylon for drain. 3-0 silk for bolster. 3-0 vicryl for “SFS”, 3-0 v-lock.
Resident tips:
Like usual for Dr. Wong breast cases, start with 150 cc of epi tumescence (without local anasthetic) infiltration into each breast using spinal needles and 50 cc syringes.
Dr. Wong likes POST-operative blocks (anasthesia choice: pectoralis, paravertebral etc..) after the case and before extubation.
For double incision approach, Dr. Wong does not obliterate the IMF. She infact uses three 2-0 PDS sutures with 3 points to preserve it while closing.
If breasts are not ptotic, then you have to match the lower line to the upper which you set just above the pigmented areola instead of the usual matching the upper incision to pitanguy's point.
She usually starts at the inferior markings, but in case of non-ptotic breasts, she will start at the superior incision.
Match thickness of flap to belly flap.
Feel free to grope palpate Dr. Wong's side as much as you need.
This operation is hard to due without assistance. Be careful not to button hole skin if you don't have an assistant.
Dr. Wong uses 10 blade to excise through breast tissue.
To thin nipples, take 4 mosquito clamps N / S / E / W and pinch dermis, not epidermis. Thin with mayo scissors over your finger. Beware of your depth. Fenestrate x 5 with 15 blade.
Post-Operative Instructions:
- Okay to shower after 48 hours
- Okay to remove dressing except for drains and yellow bolster in 48 hours
- No lifting greater than 5 lbs
- Please call to confirm your follow up in 1 week
- No NSAIDs for 2 days
Breast Revision
Suture: 3-0 vicryl for closing capsule or deep layer, 3-0 monocryl, 4-0 monocryl Dressing: Dermabond, steristrip over tails, Bra
Breast Reduction
Dr. Wong wants you to print out AP pre-operative photo and tape it up in the OR. Remember to take it down at the end of the case or you will be fired.
pre-op mark sternal notch, breast merridian can use draped ruler over neck. Imf and then pitanguy point for nipple placement. Uses tumesence 1mg epi in 1L NS
There was a superior medial powder-coat bilateral breast reduction. Unfortunately, I've learned today that the patient had a hematoma. The side that I had the steps to this operation are to first mark out to your pedicle and to de-ep that area. Of note, she does want you to print out the sheet of the patient's breasts pre-op to hang in the operating room. Once your pedicle is de-ep you can then cut your pedicle out going straight down to the chest wall if possible.
Next, you will make your triangular mastectomy superior flap about two centimeters thick and then cut out the rest of the remaining breast. Before cutting she does inject with tumescence, but this is really epinephrin one milligram of epinephrine in a bag of saline. She injects about six syringes worth or about 360 CCs per side. She does not use any local anesthetic in this, so she can use it later.