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Table of Contents
Introduction
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Operative Reports
Pectoralis Flap (Pedicled)
Operative Report
We began by thoroughly irrigating the wound with 3L normal saline. The defect measured 17 cm transversely and 15 cm vertically. The pectoralis major muscle fascia had been stripped bilaterally, but there was healthy granulation tissue forming. There was also a 4 cm by 5 cm muscle defect on the left. Skin flaps were raised circumferentially, more extensively to the left inferolateral direction. Once the lateral edge of the PM muscle was identified, dissection was carried in a submuscular plane. Its inferior attachments and medial attachment to the sternum were released. Its supplying pedicle, the pectoral branch of the thoracoacromial artery, was identified on the undersurface and preserved. The PM was freed from its medial clavicular attachment. The PM was then divided lateral to the pedicle for advancement and rotation.
The wound was again thoroughly irrigated and adequate hemostasis was obtained. Two 15 French round Blake drains were placed, one of the left side and one on the right side, and secured in place with 3-0 Nylon sutures. The PM muscle flap was advanced and rotated medially and superiorly to cover the exposed bone and secured in place with figure-of-eight 3-0 Vicryl suture to the chest wall. A 2-0 Monocryl suture was used to purse-string the skin flaps, leaving a 12 cm by 13 cm wound.
A 0.012“ split-thickness skin graft was harvested from the left thigh and meshed in a 2:1 fashion. It was stapled in placed to the chest wound and a wound vac consisting of Xeroform and black sponge was placed over the graft. There was good suction and seal. The drains were dressed with Biopatches and Tegederm. 30 ml of 0.25% bupivicaine with 1:200,000 epinephrine was injected into the thigh donor site for local analgesia.
The thigh donor site was dressed with Tegederm, ABD pads, Kerlix, and ACE wrap.
A post-operative block was administered by the anesthesia team. See their procedure note for details.
Drains: 15 french blake x2
Anatomy
Mathes and Nahai Type V - IMA perforators and pectoral branch off thoracoacromial which is dominant.
Insertion is at the bicipetal groove of the humerus. Relationship of LD and teres major is “a lady between two Majors.” This can be disinserted for more rotation.
The pedicle is in the fat superior to pectoralis minor. Burn down on the minor and not the fat or the flap will die.
Post-operative care: No lifting greater than 10 lbs for 2 weeks.
Attending Pearls
Start with an area that you know you can elevate. The inferior portion that you elevated for TE or breast aug is usually a safe space.
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.
Marks 4th intercostal space for nipple placement.
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.
Draping: 1) Drape arms with mayo stand covers, 2) Tuck half sheets into patient's sides, 3) Surround surgical site with green towels, staple in place. Make sure towels are as low as possible to OR table. 4) U drapes above and below waist
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 do 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.
Measures nipple placement. Usually about 11-13 cm from midline and 2-3 cm above IMF. Uses the eye test. Remember they are more lateral than female nipples.
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
F to M Mastectomy Peri-Areolar (Ω incision) with Inferior Dermoglandular Pedicle
Operative Report
The operative area was infiltrated with 120 mL into each breast of tumescent fluid. Tumescent fluid consisted of 1 liter of normal saline, and 1 mL of epinephrine 1:1000.
The inferiorly based dermoglandular nipple areolar complex (NAC) pedicle was marked as well as a superior omega incision marked. A 25 mm cookie cutter was then used to mark the NAC.The pedicle was de-epithelized with #15 and #10 blades leaving the NAC in place, taking care not to injury the NAC. The superior omega incision was made sharply and using electrocautery bovie a superiorly based subcutaneous flap was created to match the patients abdominal wall thickness. The dissection continued to two finger breaths below the clavicle and one finger breath from midline. Next, the an inferior flap was created leaving a 2cm dermoglandular pedicle posterior to the NAC. The dissection continued two finger breaths below the intramammary fold in order to obliterate it. With the flaps complete, the breast tissue was dissected off the chest wall with the electrocautery. Both side flap thicknesses were compared and matched by removing additional tissue with curved mayo scissors. Hemostasis was obtained. The pockets were irrigated. 15 french drains were placed in each side.
The dermoglandular pedicle and incision were stapled in place. The skin was tailor tacked and the dermoglandular pedicles were expanded on each side to remove lax skin. The marked areas were de-epithelized. The omega incision deep tissue was closed with 2-0 vicryl sutures. The dermis was closed with 3-0 monocryl followed by a 4-0 monocryl subcuticular suture. A central small wedge of the NAC was excised in order to reduce the projection of the NAC. This was closed with a 5-0 prolene suture.
The incisions were dressed with steri-strips and exofin glue was placed on the steri-strips boarding the NAC. A Biopatch and tegaderm were placed over the drain sites. Tegaderm and telfa were placed over the incisions. A compression garment was placed on the patient's chest.
Marks 4th intercostal space for nipple placement.
Drains: 2x 15 french Blake drains, 1 on each side
Dressing: Prineo (or steristrips and glue), telfa tegaderm, biopatch and tegaderm for the drain.
Sutures: 2-0 vicryl deep. 3-0 nylon for drain. 3-0 deep dermaland 4-0 monocryl subcuticular.
Draping: 1) Drape arms with mayo stand covers, 2) Tuck half sheets into patient's sides, 3) Surround surgical site with green towels, staple in place. Make sure towels are as low as possible to OR table. 4) U drapes above and below waist
Resident tips:
Like usual for Dr. Wong breast cases, start with 120-180 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.
Mark 4th interocostal space.
Inferior dermoglandular pedicle with superior omega 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 do 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.
Measures nipple placement. Usually about 11-13 cm from midline and 2-3 cm above IMF. Uses the eye test. Remember they are more lateral than female nipples.
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.
DESCRIPTION OF PROCEDURE: The patient was transported to Operating Room M #1 and placed supine on the table with pressure points appropriately padded. A pre-anesthesia time-out was performed. The patient was administered anesthesia without complication. Pre-operative antibiotic prophylaxis was administered with 2 grams of IV Cefazolin. 180 ml of tumescence (1 ml of 1:1,000 epinephrine in 1L normal saline). The surgical field was prepped and draped in the usual sterile fashion. A final time-out was performed.
An identical procedure was performed on both sides. Surgical markings were done in the pre-operative holding bay to indicate a superomedial pedicle with Wise-pattern skin excision. The new nipple-areolar complex was marked using a 42 mm cookie cutter and excised in a partial thickness fashion. The surrounding skin overlying the pedicle was de-epithelialized with a scalpel. Skin overlying the remaining areas of excision were removed in a full-thickness fashion.
The superomedial pedicle was developed with Bovie electrocautery to the chest wall, making sure not to undercut the pedicle. The nipple-areolar complex at this time appeared healthy and viable. The superolateral skin flap was developed, maintaining a thickness of 2 cm with even contour compared to the contralateral side. This was carried down to the chest wall superiorly. We preserved the breast tissue at the inferomedial aspect in order to maintain medial fullness. The remaining lateral aspects of the breast were excised. The breast excision was then passed off as specimen (right side weighing 843g and left side weighing 855g). Some of the medial breast tissue was debulked to facilitate closure.
The this point the skin was temporarily stapled close and the patient raised to a seated position. On palpation and visual inspection, both sides appeared equivalent from a volume standpoint. We tailor tacked the T-incision to improve the contour bilaterally. The areas of excision were marked. The patient was returned to a supine position and the skin was excised sharply with a scalpel.
The staples were removed and the wound was irrigated thoroughly with normal saline. Adequate hemostasis was obtained. The superior pole was further dissected superiorly with Bovie electrocautery to accommodate the rotated pedicle as well as facilitate superior pole fullness. The skin was again stapled closed temporarily. Scarpa's layer was closed with 3-0 Vicryl suture and the inframammary fold was closed with running 3-0 V-Lok suture. The nipple-areolar complex and vertical limb were closed with buried deep dermal 3-0 Monocryl followed by running 4-0 Monocryl. The incisions were dressed with SteriStrips and Exofin glue. The patient was placed into a surgical bra with gauze fluffs.
On completion of the case, bilateral nipple-areolar complexes appeared healthy, well-perfused, and viable.
The anesthesia team then performed bilateral pectoralis blocks for post-operative analgesia. See their Procedure note for complete details.
The patient was awaken from anesthesia and transferred to the PACU in good condition with no apparent complications.
Specimens: bilateral breast tissue
POSTOPERATIVE PLAN: - Discharge home. - Keep surgical bra on at all times except to shower. - Okay to shower beginning POD 2. - OTC analgesics for pain. Oxycodone as needed for breakthrough pain. - Follow up in Plastic Surgery clinic for wound assessment.