Plastics

Operative Report:
1. Revision breast reconstruction major with capsulectomy and capsulotomy bilaterally, removal of bilateral tissue expander, placement of bilateral silicone breast implants for reconstruction, scar revision to breasts 15cm total length

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.

We then focused on the bilateral breasts and their areas of tethering and asymmetry. The bilateral breasts had the old scar excised based on very thin poor quality skin and widened appearance. Total length of scar revision to chest 15cm.

Dissection was carried slightly above the incision to enter the capsule. On the right there was a X cc MV intact tissue expander. On the left was the same. A lighted retractor was used along with electrocautery to perform a capsulotomy and capsulectomy bilaterally. The pocket was opened to create a symmetric and round pocket bilaterally. The right pocket was lowered significantly at the IMF to provide better symmetry. This involving incising the capsule an dissecting precisely to created a nice IMF fold. This was was secured with 2-0 PDS in an interrupted fashion to try to re-approximate the IMF. Multiple sizers were used to determine the ideal shape and position.

Hemostasis was confirmed. Both pockets were then irrigated copiously with saline and the skin was also cleansed. Gloves were changed and new instruments were used. SS X cc implants were place bilaterally into the pockets with care to avoid contamination. The incisions were then tailor tacked closed and the patient sat up multiple times to confirm symmetry. The left breast had some excess skin and ptosis and therefore this was trimmed utilizing the current transvere incision. Once we were satisfied with the appearance, the capsule was closed with 2-0 vicryl interrupted. The dermis was closed with 3-0 monocryl and a 4-0 monocryl for intracuticular sutures.

Dermabond was applied to the breast incisions. She was placed into a surgical bra with fluffs. She tolerated the procedure without difficulty and was extubated and transferred to recovery in stable condition.

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…

Learning points/Pimp Questions:

Operative Report:
1. Repair of split earlobe

With the patient sitting, the margins of the clefts were marked. The area was then infiltrated with 2 cc of 1% lidocaine with epinephrine and 0.5% bupivicaine. Adequate time was allowed for hemostasis and anesthesia.

The patient was placed in supine position on the bed. The procedure was performed on the right side. The margins of the cleft were incised sharply with an 11 blade scalpel to create a V-shaped excision pattern. The inferior margin was carefully cut to make sure it would allow for proper approximation.

The wound was completely closed with a 5-0 chromic suture in an interrupted fashion. The first suture being placed at the inferior margin to ensure no notching. The anterior surface of the ear lobule was done first followed by the posterior surface. At the conclusion of the procedure all edges are well approximated and there was a nice smooth curvature to the helix. Following this the patient was again cleansed and Steri-Strips were applied.

The patient tolerated the procedure well and without complication she was given followup instructions and I will see her in one week time.

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…

Learning points/Pimp Questions:

Operative Report:
1. Breast reconstruction with direct to implant reconstruction and acellular dermal matrix. Intraoperative SPY angiography to assess perfusion.

The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol.  A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision. Please refer to the breast surgeon's op note for full details of the mastectomy. Mastectomy Weight: X g

At the time that I was called into the OR, the mastecomy had been completed.  I began with the first side - the mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery.  Spy angiography was utilized to assess the perfusion to the mastectomy flaps.  All areas of the mastectomy flap appeared viable except for a small portion at the superior aspect which had a relative perfusion of less than 30%.  These were debrided with 15 blade and electrocautery.  I then irrigated the pocket with saline.  A sheet of 16 X 20  cm size AlloDerm which was perforated by myself had been prepared as per manufacturers guidelines was then placed into the wound.  It was initially sized to the wound using a # sizer.  Once the excess AlloDerm was trimmed it was placed into the wound and sutured into position in the medial superior and lateral aspect using interrupted 2-0 Vicryl sutures.  The same sizer was then placed into the wound and it was closed temporarily.  The patient was set up multiple times to assess for symmetry and implant position.  Once were happy with the appearance and excellent symmetry we then performed another spy angiography run to assess for blood perfusion.  All areas were greater than 30% relative perfusion at this time with the implant in position.  I then removed the sizer irrigated the pocket again with saline and we prepped the skin with betadine.  Gloves were exchanged and an implant was placed into the pocket.  The inferior aspect of the incision was then closed with interrupted 2-0 Vicryl sutures suturing it to the chest wall.\\ 
Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline.  Two 15 blake drains were placed and sutured with a 2-0 nylon. The entire edge of skin was subsequently de-epithelialized.  The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl intracuticular.

The wounds were cleansed and dressed with Biopatches for the drains and dermabond applied to the incisions.  She was placed into a surgical bra with fluffs.  She was extubated and transferred to recovery in stable condition.  

Photos

Tourniquet: finger / forearm / arm
Drain: 2 X 15F Blake drain
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed\\Post-operative care: Include restrictions, splints, etc…\\Learning points/Pimp Questions:

Operative Report:
1. Breast reconstruction with DIEP flaps - S code
(22 modifier if S code not applicable, muscle preservation and length of dissection)
2. SPY fluorescence imaging of skin perfusion based on perforator dissection
3. Debridement of mastectomy flap skin total length X cm

The patient was marked preoperatively in the holding area for anatomic landmarks, as well as the above-mentioned surgery. 5000 units of heparin was given subcutaneously in the preoperative area.

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. Foley catheter was placed.The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.

The co-surgeon for this free flap due to the complexity and difficulty in DIEP dissection, and the need for advanced microsurgical expertise. This operation qualifies for the S code due to the above reasons.

We utilized a two team approach. Dr. X exposed the mammary vessels.

Initially, the breast footprint was created by raising the mastectomy flaps full thickness above the pectoralis - bilaterally. We then identified the 4th rib costal cartilage and the pectoralis muscle was split longitudinally to access it. The perichondrium was scored and elevated circumferentially. The entire costal cartilage was removed. We then split the posterior perichondrium and elevated it off the IM vessels. The IMA was evident beneath a thick layer of scar and was dissected free for the entire interspace. We then proceeded to dissect out the IMV. Dissection was carried to the cephalad rib. The artery was approximately ? mm and the vein was ? mm.

We then dissected out the vessels on the contralateral side and the exact same approach was utilized. The artery was at least ? mm and the vein was ? mm.

During this time we began the flap elevation portion of the operation. A circumferential incision was created with a 15 blade around the umbilicus. The umbilical stalk was freed from the surrounding soft tissue using electrocautery. The superior incision was then made. This was carried to the xiphoid and costal margin. The patient was flexed and the lower incision line was confirmed. We then made the lower abdominal incision. This was carried down to the SFS layer and the SIEV's were identified and dissected for ? cm. The flap dissection was then carried down to the rectus fascia.

We then elevated the flap from lateral to medial starting on the first side . The lateral row had X# perforators and we then made the midline incision. The midline was then split and we began the dissection on the from medial to lateral. There were X# medial row perforators that were identified. We decided to base the flap off the medial vs lateral row due to the size, position and quality.  The remaining perforators were clamped with atraumatic clamps. The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines. The flap perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise.

We then split the fascia above the cephalad perforator and around the remaining perforators. A complex intramuscular dissection was then performed to the pedicle. The selected perforators were followed through the rectus fascia and the rectus muscle, meticulously clipping, ligating, and dividing all small side branches. These vessels were followed down to their origin from the inferior epigastric artery and vein, which in turn were followed down toward their origin from the external iliac artery and vein.  This dissection took greater than 50% longer than a TRAM or MS TRAM due to the muscle splitting and preservation and the complex intramuscular course of the pedicle.  This added an additional 2 hours to each side. Flap viability was confirmed and then the donor vessels were clipped and divided. The harvested flap was then flushed with heparinized saline. The flap weight was recorded.

We then brought the flap to the contralateral chest and secured it to the chest wall. The IM vessels and DIEP pedicle vessels were then prepared under the microscope. We then used a X diamater mm flow coupler for the vein and a 9-0 nylon suture for the arterial anastomosis using standard microsurgical technique. The flap was well perfused with a doppler signal in the pedicle and on the skin.  The previous mastectomy flap edge of skin was debrided based on its damaged appearance. This full thickness skin debridement was performed over a total length of X cm. The skin paddle was measured and tailored to match the native NAC position both in size and location.

The flap was then inset after we had de-epithelialized the portion of the buried flap with facelift scissors. Careful attention was paid to in setting the flap without an twist or kink in the perforators or pedicle and this was confirmed with the flow coupler sound. Approximately a 42mm NAC skin paddle was created for future nipple reconstruction. A electrocautery scoring was performed into the flap in order to allow the skin paddle to match the mastectomy with no step-off. 2-0 vicryl suture were used to secure the flap to the chest wall in the anatomically correct position and improve shape. A 15 blake drain was then placed secured with 2-0 nylon and the flap inset with 3-0 and then 4-0 moncryl sutures.

We then turned our attention to the contralateral flap with a near identical procedure.

The rectus muscle split was repaired with 2-0 vicryl in a figure of eight. The rectus fascia defect was then closed with buried interrupted 0 PDS in an figure of eight fashion. A running 0 PDS was used to tighten the closure. Two 15 blake drains were then placed. All drains were secured with 2-0 nylons and a biopatch. The skin was then closed with a 2-0 vicryl for Scarpa's fascia and 3-0 monocryl for the deep dermal layer. The skin was closed with 4-0 running subcuticular suture. The umbilicus was then incised on the abdominal wall the the umbilical stalk delivered slightly above the ASIS in an anatomically ideal position. The umbilicus was then inset with 3-0 monocryl deep dermal sutures and 4-0 monocryl in a running fashion. The skin was then dressed with dermabond and prineo. A Pravena incision VAC was placed to assist with healthy wound healing on the abdomen.

The patient tolerated the procedure well and without complication. She was brought to the PACU in stable condition. At the time of extubation and transfer to recovery she had a doppler signal on the skin and flow coupler.

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…
Learning points/Pimp Questions:

Operative Report:
1. Right breast reduction for symmetry; left breast reconstruction revision major; fat grafting to left breast 170cc from bilateral medial thighs; abdominal scar revision 8cm

The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks as well as a wise pattern breast reduction using a standard template. Her DIEP flap was also marked for a reduction in skin paddle and elevation as well as the donor site for fat grafting from bilateral ankles. We also marked the small bilateral standing cone deformities on the abdominal incision.

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped with chloroprep and draped in the standard fashion.

For the standing cone deformities we performed a scar revision over a total length of 8cm accounting for both sides. These were resected with a 15 blade then cautery. This was closed with 3-0 and 4-0 monocryl and dressed with dermabond.

A 42mm cookie cutter was used to mark a new ideal nipple areolar complex size on the right breast. A 8 cm wide superomedial pedicle was then de-epithelialized using 10 blade. The superomedial pedicle was then dissected away from the surrounding breast tissue down to the chest wall using electrocautery. The nipple was pink and viable during this process. I then removed the medial, lateral and inferior breast tissue from the wise pattern outline. Once the resected specimen was removed the skin was tailor tacked with a stapler. 15cc of 0.5% Marcaine with 1:200,000 epinephrine was infiltrated in the pectoralis major muscle fascia for perioperative analgesia. A total of X g of tissue were resected from the right breast. The IMF, vertical limbs and periareolar incision were then closed with 3-0 monocryl into the dermis followed by a 4-0 running monocryl intracuticular. Dermabond was then applied all incisions with Prineo to the IMF and T junction.

I then turned my attention to the contralateral breast. The downsizing of the left skin paddle was performed to produce a symmetric 42mm reduction. The mastectomy flaps were undermined completely to help elevate and medialize the flap. The DIEP flap was completely repositioned superiorly and medially. There was a T junction of skin which needed to be resected on the mastectomy flaps in order to achieve this result. The patient was sat in an upright sitting position to assess for size, shape, and symmetry of the breasts.  All necessary adjustments were subsequently made to achieve excellent symmetry. Meticulous hemostasis and copious irrigation was then performed.

I then turned my attention to fat grafting. Her donor sites were marked in preop - bilateral medial thighs. I infiltrated X cc of standard tumescent solution after making a small incision with a 11 blade into each thigh. After waiting a suitable period of time I then began lipoaspiration. Great care was taken to avoid deep suction and to avoid contour deformity. The fat was collected sterilely and prepared using the Revolve system I then placed the fat in sterile syringes for injection. The incisions were closed with 5-0 fast gut. A total of X cc of fat were initially harvested.

I then added total of X cc of fat graft to the left breast. This was infiltrated as per Coleman technique in the previously marked areas of deficit in the superomedial areas of her breast reconstruction as well as symmetrically throughout the whole flap for greater volume. The injection sites were closed with a 5-0 fast gut. These incisions were dressed with steristrips and opsite dressings.

She was placed into ACE wraps for the legs.

The nipples were viable at the end of the procedure and the breasts soft. She was placed into a surgical bra with ABDs. The patient tolerated this procedure without complication, and postoperatively she was extubated and brought to the recovery room in stable and satisfactory condition.

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…\\Learning points/Pimp Questions:

Operative Report:
1. Bilateral brachioplasty

The patient was marked preoperatively in the holding area in an upright standing position for anatomic landmarks as well as an elliptical excision pattern of the bilateral upper arms.

The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped with chloroprep and draped in the standard fashion.

A near identical procedure was performed on both arms.

After markings were confirmed anterior incisions were made with a 15 blade scalpel. No axillary Z-plasty or dissection was needed based on patient habitus. Dissection with electrocautery was subsequently performed down to biceps and triceps muscle fascia.  Careful attention was paid to stay above the fascia and leave a small amount of tissue at this plane.  Once a significant amount of tissue had been elevated and markings were confirmed for ease of closure at the posterior skin incision was also made.  This was also dissected down to the level of the muscle fascia.  The medial antebrachial cutaneous nerve was not found with in the wound due to the posterior position of the incision.  Meticulous hemostasis was obtained throughout the operation.  Once initial resection was performed bilaterally the resulting contour was compared for symmetry on both sides using tailor tacking with staples. We confirmed a symmetry and anatomically harmonious result with minor additional alterations. The wounds were then irrigated with antibiotic saline.

Final resection weights:

30cc of 0.25% Marcaine with 1:200,000 epinephrine was infiltrated in the skin incision. A 15F round drain was placed into each wound and sutured in position with a 2-0 Nylon. The Scarpas layer was closed with 2-0 vicryl in an interrupted fashion. The deeper dermis was closed with a 2-0 PDO V-loc and the superficial dermis and epidermis was closed with a running 3-0 monocryl. Dermabond was then applied all incisions. The wound was dress with Telfa, Kerlix and ACE wraps from the hand to axilla

Photos

Tourniquet: finger / forearm / arm
Drain: 2X 15F round drains
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report:
1. Anterolateral thigh flap 7 x 15 cm to right lateral foot. Intraoperative SPY angiography to assess perfusion.

The patient was taken to the operating room and placed supine on the operating room table. The right lower extremity was prepped and draped in standard, sterile fashion.  Preoperative time-out was performed confirming site and laterality, patient, procedure to be performed, and IV antibiotics.

Following this, attention was first turned to the wound.  The margin of necrotic skin was excised with a #15 blade scalpel circumferentially including a small portion of glabrous skin.  There was bleeding tissue at the margin and exposed bone, therefore, a piece of this bone was sent for pathology.  Skin, subcutaneous tissue, fascia, down to and including bone was then debrided 7 x 5 cm.  The site was copiously irrigated.  This was templated out onto an elliptical pattern for an ALT and the intervening skin to the AT and DP vessels was excised keeping intact the underlying fascia covering tendon.  This was then transposed onto his right thigh in the site of a perforator for an ALT 7 x 15 cm. Anterior incision was made down to crural fascia.  LFCN was identified, carefully preserved.  Single perforator was identified.  This was traced through an intramuscular course in the descending branch of the lateral and femoral circumflex artery.  Five-thousand units of IV heparin were given.  The flap was islandized and brought down to the foot. The flap was cut back on the pedicle given the position so that a end-to-side into the DP with the perforator was completed, with 9-0 nylon, and a vein within each branch draining both comitantes into a single outflow was coupled into comitantes of the DP with a 2-0 coupler.  Clamps removed, demonstrated excellent flow.  The flap was inset with 3-0 nylon.  The thigh was closed by repairing the muscle with 3-0 PDS.  The skin was then closed with 3-0 nylon over a #15 round Blake drain.

Following this, the flap appeared well perfused.  Good Doppler signal on a Vioptix marker and therefore a well- padded dressing was applied.  He was awoken from anesthesia, and transported to the PACU in stable condition.

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…

Learning points/Pimp Questions:

Operative Report:
1. Vertical rectus abdominis flap
2. Complex closure
3. SPY fluorescence angiography
4. Exploratory laparotomy closure

The patient was brought into the operating room and placed in the lithotomy position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.

At the conclusion of the colorectal surgery team as well as the gynecological oncology team resections, I was called into the OR, the defect was extensive and had a large pelvic volume requirement. The initial size of the wound was approximately ? cm x ? cm of the pelvic floor. There was a small cuff of vagina remaining as well. The defect was reassessed and a 8 cm skin island was needed over the entire vertical length of the rectus muscle.

I then began the flap elevation of the right VRAM. A 8 cm wide VRAM was designed around the periumbilical perforators. The skin was incised using a blade and and dissected down to the anterior rectus sheath using electrocautery. Of note this patient did have a significant adipose layer. The flap was then dissected carefully using cautery along the rectus sheath until the medial and lateral row of perforators was encountered. This maneuver was performed to preserves as much fascia as possible for abdominal closure. Once these were located the anterior the rectus fascia was incised and the rectus muscle was immediately encountered. The flap was then elevated from distal to proximal dividing the muscle using cautery. Using a combination of cautery as well as blunt dissection, the muscle and its skin paddle was elevated to its origin at the deep inferior epigastric system and pubic ramus. Periodically 2-0 Vicryl sutures were placed in the muscle to secure it to the Scarpa's fascia to prevent shearing of the flap. The pedicle was protected in its entirety.

Once the flap was completely elevated, the SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines. The flap perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise.

The flap was subsequently passed into the pelvis to enable it to travel with minimal tension on the pedicle and perforators. The skin paddle was marked based on the defect. Our goal was to reconstruct as much of the posterior vaginal wall as possible while still providing dead space fill to the pelvis and a tension-free closure on the APR defect. The proximal portion of the skin was de-epithelialized and the flap was passed carefully into the pelvis for inset. The flap passed easily into the perineum with the muscle obliterating the floor of the pelvis. The muscle was inset with 2-0 PDS and a 15 French Blake placed to drain the deep perineal space and sutured to the skin anteriorly using 2-0 nylon. The skin was then inset with 2-0 PDS for scarpa's fascia layer and 2-0 vicryl in a horizontal mattress fashion for the skin. The posterior aspect of the pelvic resection was able to be closed primarily. This involved a complex closure of multiple layers including fascia, subcutaneous tissue, dermis, and epidermis using 2-0 PDS as well as 2-0 Vicryl over an entire length of approximately 7 cm. A 15 French Blake drain was also placed into the anterior rectus sheath and sutured to the skin using 2-0 nylon.

Due to the fact that the Gyn/Onc team as well as the colorectal team was unavailable to close the exploratory laparotomy incision, I elected to perform this portion of the procedure. A 2-0 PDS suture was used to repair the posterior rectus sheath in a figure of 8 fashion over its entire length. The anterior rectus fascia was then repaired using a looped 0 PDS. The deep Scarpa's layer was subsequently repaired with a 2-0 Vicryl in an interrupted fashion. A 3-0 stratafix suture was used to repair the dermis over the entire length of the incision and a 3-0 Monocryl suture was used as an intracuticular stitch for aesthetic closure of the epidermis. The wound was subsequently dressed with Dermabond and an OpSite dressing. The pelvic wound was dressed with fluffs and mesh underpants. Drains were dressed with bio patches and Tegaderms.

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…

Learning points/Pimp Questions:

Operative Report:
1. Bilateral subcutaneous mastectomy and free nipple graft

The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision.   A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion using chloroprep.   In the preoperative suite the IMF was marked and along with the proposed resection specimen to create a straight transverse resultant scar.  This was confirmed with the patient and great care was taken to ensure that the medial extent of the incision was >2cm from the midline.

I began with the right breast. A 25mm cookie cutter was used as a template for the new nipple.  The nipple was excised full thickness and the breast tissue and excess soft tissue was removed with sharp iris scissors. The nipple graft was placed in a moist lap pad for later use.  I then made the superior incision.  The superior flap was raised to the chest wall at 1cm of thickness with careful attention to remain evenly in the junction between the subcutaneous tissue and the breast parenchyma. Adequate tissue for closure was confirmed. Once this was completed, the lower incision was made straight down to the chest wall. All excess overhanging skin at the border and irregularities were smoothed out. The breast tissue and skin were then dissected completely off the chest wall from medial to lateral being sure to leave pectoralis and serratus muscle fascia intact. The specimen was passed off to pathology for review per protocol.  The wound was thoroughly irrigated and bleeding controlled using cautery.  A temporary closure with tailor tacked staples was performed.

I then turned my attention to the contralateral breast and the exact same procedure was performed.  The patient was sat upright multiple times to confirm symmetry and ideal male chest contour. A 15 blake drain was placed on each side and secured to the skin using 2-0 nylon suture.  The mastectomy flaps were then advanced to the lower marking with careful attention to keeping the incision as transverse as possible. A 3-point 2-0 vicryl suture was used to tack both the upper and lower flaps to the chest wall. The remainder of the incision was closed with 3-0 and then 4-0 monocryl sutures.

Mastectomy Weights:
Right:
Left:

Special attention was paid to the lateral chest wall to remove as much of the standing cone deformity as possible.

The patient was again placed in the upright position.  The new nipple location was placed in the aesthetic ideal position. This was deemed to be ? cm from the midline and ? cm from the inferior incision. Symmetry was confirmed.  The template was used to de-epithelialize the nipple graft bed and convert the round nipple to a male horizontal oval ideal shape.  This base was well vascularized and the nipple grafts were sutured with 5-0 chromic suture in an interrupted and continuous fashion. The nipple grafts were secured with bolster dressings of cotton balls, mineral oil, and xeroform using 2-0 silk sutures. The incisions were then dressed with dermabond, op site and an abdominal binder to the chest. The drains were dressed with bio patchs and tegaderm.

The patient tolerated the procedure well and without complication and was transferred to recovery in stable condition.

Photos

Tourniquet: finger / forearm / arm
Drain: 15 blake drain x2
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report:
1. Bilateral breast reconstruction revision for asymmetry, bilateral tissue expander removal and silicone implant placement. Scar revision bilateral breast 12cm in total length for both sides.

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision.

Identical procedures were performed on both sides. The previous IMF scars were full thickness excised using a 15 blade scalpel based on their thickness.

Dissection of the mastectomy flaps was made above the fold using electrocautery to create a stair-step for entry into the pocket. The capsule was subsequently entered in a stairstep location at a higher aspect of the breast. The current tissue expander was removed and inspected and determined to be intact without evidence of infection or rupture. The capsule was also opened medially and superiorly to better accommodate the implant size and allow a better contour. Specifically on the left breast the IMF was lowered by 1 cm and opened medially and superiorly. The left pocket was also revised to remove nonviable Alloderm and opened superiorly and medially. Initially sizers were placed into the pocket.

Patient was set up multiple times to confirm symmetry. Once we were happy with excellent symmetry the pockets were irrigated with Betadine and antibiotic irrigation. Meticulous hemostasis was performed. The skin was recleansed with Betadine. Using a new set of gloves new implants were placed with careful attention not to touch the skin.

Once the implants were in position and properly seated the capsule was closed with a 2-0 Vicryl in interrupted fashion. The deeper dermis was closed with a 3-0 Monocryl in the superficial dermis and epidermis were closed with a 4-0 Monocryl. The wound was subsequently cleansed again and dressed with Dermabond. Dressings consisted of a surgical bra with ABDs.

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…

Learning points/Pimp Questions:

Operative Report:
1. Breast tissue expander removal and drain placement
2. Scar revision
3. Washout of breast

The patient was brought into the operating room and placed in the supine position.  All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia.  All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion using chloroprep.

I opened up the breast prior incision with a 15 blade and noted a moderate amount of purulence concerning for infection. A culture was taken for microbiology. We then washed out the pocket thoroughly using pulse lavage with 3L of saline. Hemostasis was performed throughout the pocket thoroughly. A rim of inflamed nonviable skin was removed as a scar revision. A 15F blake drain was placed onto the right side and secured to the skin using 2-0 nylon suture.  The incision was subsequently closed with with 3-0 and then 4-0 monocryl sutures.

The incisions were then dressed with dermabond, ABDs and an bra. The drains were dressed with bio patchs and tegaderm.  

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…

Learning points/Pimp Questions:

Operative Report:
1. Bilateral breast reconstruction with tissue expander (pre-pectoral) and acellular dermal matrix

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision. Please refer to the breast surgeon's op note for full details of the mastectomy.
Mastectomy Weight: R g; L g

At the time that I was called into the OR, the mastecomies had been completed. I began with the right side - the mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery. I then irrigated the pocket with saline and measured the breast footprint. Two sheets of 16 X 8cm had been prepared as per manufacturers guidelines was then were then sutured together ex-vivo using 2-0 vicryl. Gloves were exchanged and an expander was placed into the ADM and completely wrapped circumferentially (deflated) using 2-0 vicryl. The suture tabs were exposed through small openings. The pocket was again irrigated with betadine and saline. We prepped the skin with betadine. The completely wrapped TE with ADM was then sutured to the chest wall with 2-0 Vicryl in the proper orientation and position.

The tissue expander was filled to ? cc of sterile saline using the port such that there was minimal tension on mastectomy flap skin.

Hemostasis was then confirmed again and the pocket irrigated with saline. Two 15 blake was placed and sutured with a 2-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl intracuticular.

I then turned my attention to the contralateral breast. The exact same procedure was performed on that side.

The wounds were cleansed and dressed with Biopatches for the drains and dermabond applied to the incisions. She was placed into a surgical bra with fluffs. She was extubated and transferred to recovery in stable condition.

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…

Learning points/Pimp Questions:

Operative Report:
1. Breast reconstruction with tissue expander and acellular dermal matrix

Expanders
R: 133S-MV-T cc; SN #
L: 133S-MV-T cc; SN #

Alloderm Lot #:
R:
L:

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.The patient received preoperative antibiotics prior to surgical incision. Please refer to the breast surgeons op note for full details of the mastectomy.

Mastectomy Weight: g

At the time that I was called into the OR, the mastecomies had been completed. I began with the right side - the mastectomy flaps were viable and hemostasis was obtained with bovie electrocautery. I then irrigated the pocket with antibiotic saline. The pectoralis was then elevated and divided at its inferomedial origin. The perforators were controlled with cautery and medium clips. A sheet of alloderm which had been prepared as per manufacturers guidelines was then placed into the wound. It was then inset to the IMF and lateral breast border with a 2-0 vicryl. I then irrigated the pocket again with antibiotic saline and we prepped the skin with betadine. Gloves were exchanged and an expander was placed into the pocket (deflated). The suture tabs were sutured to the chest wall with 2-0 Vicryl. I then closed the interface between the pectoralis and acellular dermal matrix with a 2-0 vicryl in a running fashion. The tissue expander was filled with sterile saline using the port such that there was minimal tension on the pectoralis muscle pocket or mastectomy flap skin.
Hemostasis was then confirmed again and the pocket irrigated with antibiotic saline. One 15 blake was placed and sutured with a 2-0 nylon. The skin was then closed with a 3-0 monocryl for the deep dermal layer and a 4-0 running monocryl intracuticular.

I then turned my attention to the contralateral breast. The exact same procedure was performed on that side.

The wounds were cleansed and dressed with Biopatches for the drains and dermabond applied to the incisions. She was placed into a surgical bra with fluffs. She was extubated and transferred to recovery in stable condition.

Photos

Tourniquet: finger / forearm / arm
Drain: 15F Blake drain for each side
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Learning points/Pimp Questions:

Operative Report:
1. Preparation of wound bed
2. split thickness skin graft
3. wound vacuum placement

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard sterile fashion.

The operation began with preparation of the wound bed. The skin edges were debrided with ? to remove all non viable tissue over the entire wound . The wound was then debrided of excess granulation, retained vac sponge, and debris with gentle scrapping. 3 liters of normal saline was used as lavage with cysto tubing.

A template was created and then transferred to the thigh and a dermatome set at 12 one thousandth of an inch thickness was used to obtain a STSG. The skin graft was then meshed at 1:1.5. It was placed on the wound bed and secured with staples and 4-0 chromic suture. A VAC dressing was then applied over adaptec and the graft then placed at 125mmHg continuous. Minimal leak was noted. Of note this VAC was an inpatient version which is durable medical equipment and not disposable and will remain in position for 5 days while the patient is admitted to the hospital. The lower leg was then wrapped with a loose kerlix and ACE warp. The donor site was managed with mepliex dressing and then wrapped with a large ACE.

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…\\Learning points/Pimp Questions:

Operative Report:
1. Reconstruction of spinal defect with bilateral paraspinous muscle flap closure vs complex wound closure and incisional VAC placement

Upon completion of spine surgery's portion of the case including but not limited to proper positioning, padding, and monitoring, plastic surgery commenced our portion of the case.  The wound was examined closely and the defect was identified. The wound was 15 cm in length. We initially irrigated and meticulous hemostasis was obtained.  Based upon the significant hardware and close proximity to the spine this was deemed appropriate for muscle flap coverage of this area.  The plane was made above the paraspinal muscles in the superior aspect of the incision using Bovie electrocautery. The left paraspinal muscles were identified and the anterior investing fascia was dissected to the lateralmost border. The segmental perforating blood supply over the posterior intercostals was identified.  Release of the lateral fascia was performed using cautery with care not to damage the neurovascular structures. The paraspinal muscle were then freed to transport medially.  The goal of the muscle release was to transport both muscles medially to allow for closure of dead space as well as to provide a tension-free closure of muscular tissue overlying the hardware.
 
An identical procedure was performed on the right side.

The wound was again examined for any bleeding and meticulous hemostasis was obtained. We then placed a 2 hemovac drains below the muscular layer.  The paraspinal muscles were then sewn to themselves in the midline using a 0 PDS suture using a figure-of-eight fashion.  This was done over the entire length of the wound and muscle. This enabled good vascularized tissue coverage over the hardware.  There was also 2 X 15 French Blake drains placed into the soft tissue fields.  Drains were sewn into position using a 3-0 nylon suture.  The Scarpa's fascia was repaired with a 2-0 PDS suture.  The deep dermis was repaired with a 3-0 Monocryl suture and the superficial dermis and epidermis were repaired with a 3-0 nylon in a running horizontal mattress fashion.  At the conclusion of the procedure all the wound edges are well approximated and the drains were holding suction.     The skin was subsequently cleansed again and it was dressed with Biopatch as for the drains. The 15 cm incision had a durable medical equipment incisional VAC placed with the use of the hemovac drains being placed into a sponge after adaptec was placed on the wound. This was covered with occlusive dressing and attached to a wound VAC and 125mmHg.   The sponge and instrument counts were correct and the patient tolerated the procedure well and he subsequently transported to the PACU in stable condition and will be followed by the plastic surgery service.

Photos

Tourniquet: finger / forearm / arm
Drain: 2 X 15F French round drains and deep wound drain and incisional VAC 
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed
Post-operative care: Include restrictions, splints, etc…
Learning points/Pimp Questions:

Operative Report
1. Panniculectomy with umbilical transposition

I marked the patient in the preoperative suite while standing. A high lateral tension approach was utilized to reduce dog ears. The lower incision was made above the mons pubis and in a dumbbell shape laterally with the maximum amount of resection marked.

The patient was brought into the operating room and placed in the supine position. All bony prominences were padded and the SCDs were on and functioning prior to the induction of anesthesia. All lines were obtained and secured and the patient was intubated and sedated as per protocol. The patient received preoperative antibiotics prior to surgical incision. A timeout was performed with the entire team and the patient was then prepped and draped in the standard fashion.

The umbilicus was dissected free from the abdominal skin using a 15 blade scalpel. Dissection was carried down to the abdominal wall being sure to leave adequate tissue to maintain perfusion. A larking stitch was placed into the umbilicus for future placement onto the abdominal wall. Next the lower abdominal incision was made with a 10 blade and then carried to just above rectus fascia with bovie electrocautery. Many large superficial veins were encountered and controlled with a combination of surgical clips and electrocautery. Dissection was carried cephalad to the superior incision which was above the umbilicus. I then confirmed that we could close the wound with a reasonable tension with a small amount of retroflex of the bed. The superior extent of the incision was then marked and incised. The pannus was then removed after all the bleeding vessels were controlled. Weight of specimen ~1500g. The wound was irrigated copiously with saline and meticulous hemostasis was confirmed. 30cc of 0.5% marcaine was added into the abdominal wall for post operative pain control. The upper abdominal skin was then tailor tacked closed. 2X19F drains were placed into the wound and secured with 2-0 nylon sutures laterally. The Scarpa's fascial layer was then closed with with 2-0 vicryl. The dermis was closed with interrupted 3-0 monocryl. The epidermis was then closed with an intracuticular 4-0 monocryl.

The umbilicus was then delivered through a new opening on the abdominal skin making sure not to twist it. This was secured in position with 3-0 monocryl and 4-0 fast gut. The wounds were subsequently dress with Prineo and Biopatches to the drain sites. The patient was then placed in an abdominal binder with ABDs for padding.

The patient tolerated the procedure well and without complication. She was brought to PACU in stable condition.

Drains: 2 X 19F round blake drains brought at lateral edge of incision
Sutures: Drains 2-0 nylon, SFS 2-0 vicryl, Skin:3-0, 4-0 monocryl. Umbilicus: 3-0 monocryl, 4-0 fast gut.
Dressing: Abdomen: prineo, Umbilicius dermabond, drains: biopatch and tegaderm, ABDs, Binder.
Markings: High lateral tension approach. Markings are dumbbell shaped.

Resident Notes:
The high lateral tension approach changes the area of greatest tension to about the 1/3rd mark of the incision and off midline. The dumbbell shape helps decrease dog ears. Dr. Cohen will mark the maximum that you can cut with his pre-op markings. In the OR, you will have to remeasure and will not get that far. Remember that the area of greatest tension is not in the middle and you are lateralizing the upper part of your skin flap.

Questions you will be asked:
If you can't close your incision what are your options? More reflex, more undermining superiorly and inferiorly, progressive tension suturing, incisional wound vac. Wedge out flap subcutaneous tissue.

place holder for op report