1. Debridement of venous stasis ulcer, right lower extremity.
2. Full-thickness skin graft reconstruction, right lower extremity ulcer, approximately 4 sq cm surface area.
DESCRIPTION OF PROCEDURE: After identification of the patient and informed consent, he was placed in the usual supine position. After induction/intubation with a laryngeal tracheal mask, the patient's right lower extremity and groin were prepped and draped in the usual sterile fashion with Betadine scrub and paint. Surgery was begun by anesthetizing the right lower extremity wound, over the medial malleolus, as well as the right groin donor site with 1% lidocaine with epinephrine. The ulcer was excised with 5 mm margin tangentially using a #15 blade scalpel. Specimen was sent to pathology for permanent section diagnosis. Electrocautery was used for hemostasis. The area was irrigated with saline and then covered with a gauze until later grafting. Template made of defect, and a full-thickness graft harvested from the right groin inguinal crease region along the resting skin tension line. Full-thickness grafts harvested with a #10 blade scalpel. Donor site was closed after local undermining using #3-0 Vicryl sutures in Scarpa’s fascia, #3-0 Vicryl sutures for subdermal tissues, and #4-0 Vicryl along the subcuticular layer. Graft was defatted, cut to the appropriate dimensions, placed in the bed, and secured with running sutures of #6-0 chromic. It was then covered with a tie-over bolster created using antibiotic ointment, Adaptic, Reston foam and surgical clips. Right lower extremity was then wrapped with Kerlix, Webril, cast padding, and placed in a posterior splint with plaster and a lightly applied Ace bandage. Donor site and groin covered with benzoin, Steri-Strips, and sterile dressing. The patient was extubated and taken to the recovery room in stable condition. No complications.
PREOPERATIVE DIAGNOSIS: Abdominal lipodystrophy.
POSTOPERATIVE DIAGNOSIS: Abdominal lipodystrophy.
DETAILS OF OPERATION: After obtaining written consent, the patient was marked in the preoperative holding area and then brought to the operating room table by anesthesia. Sequential compression devices were placed on each lower extremity, and pressure relief was placed in adequate position by anesthesia and nursing care. She was then placed under general endotracheal anesthesia. A Foley was placed. The incision lines were infiltrated with 1% Xylocaine with 1:100,000 solution of epinephrine. A total 20 mL was used. Next, she was then prepped and draped in the usual sterile fashion.
A skin incision was made in the inferior incision line. The superior skin and fat flap was dissected along the anterior fascial line. The umbilicus was excised from the anterior abdominal wall skin and kept on its stalk with good blood flow. Continued dissection superiorly to the subcostal margin bilaterally and in the xiphoid process centrally. Anterior rectus fascia sheath was plicated medially using a looped #0 PDS suture. One was run from the xiphoid to the superior umbilicus and the second one from the inferior umbilicus down to the pubic bone. This tightened up the abdominal wall.
The superior skin and fat flap was then brought down and cut to tailor the inferior incision line. All the skin below the umbilicus was excised. The lateral lines were tailored so as to remove any extra skin and prevent dog ears. Hemostasis was once again obtained using Bovie electrocautery. The wound was irrigated with copious amounts of antibiotic saline solution. Next, two flat 10 JP drains were placed.
We then proceed to close the Scarpa’s layer with interrupted #2-0 Vicryl sutures. The dermis was closed with interrupted #3-0 Monocryl sutures and the skin was closed with a running #4-0 subcuticular stitch. The drains were secured with #3-0 silk sutures. Following this, 0.25% Marcaine was injected through the JPs into the subcutaneous fascial layer. A total of 15 mL was used in this fashion.
The patient tolerated the procedure well. She was extubated and brought to the recovery room in stable and satisfactory condition.
OPERATION: Immediate stage left breast reconstruction using subpectoral tissue expanders.
DESCRIPTION OF PROCEDURE: After identification of the patient and informed consent, she was taken to the major operative suite, placed on the table in supine position. She underwent induction and intubation, obtained general anesthesia, antibiotic prophylaxis was given. Dr. John Doe performed a left simple mastectomy. Please see his separate dictated note.
Then, I performed the immediate reconstruction. I inspected the mastectomy site. I found it to be free of any bleeding. Dr. John Doe had also removed the Chemo-Port. The incision has already been closed by him. I elevated the subpectoral pocket, by using electrocautery, elevated the muscle off of its insertion and along the superior rectus fascia, approximated it to the fascia, the Scarpa's fascia, at the crease of the breast using 3-0 Vicryl sutures in a running fashion. I should note I did make symmetrical markings for the crease, medial, upper, and lateral poles of the breast based on the position of an opposite prosthesis, laterally elevated the Scarpa's fascia flap over the serratus muscle to close the lateral portion of the pocket. After developing the pocket, performed intercostal nerve blocks with 0.25% Marcaine with epinephrine, used for the surgery McGhan Style 133 FV tissue expander, 500 cc fill volume, reference # 67-133FV13, lot # 1030761, serial # 11247777. The expander was deflated of air and found to be free of any defect, placed into the pocket, and the port accessed and filled with 75 cc of sterile saline used in closed irrigation system.
The pocket was closed laterally using a running suture of 3-0 Vicryl and then #10 flat Jackson-Pratt drain was inserted through a separate stab incision in the axilla and placed on top of the pectoral muscle, secured to the skin with 2-0 silk suture. Mastectomy incision was closed in layers using 3-0 Vicryl sutures, subcutaneous tissue with 3-0 Vicryl sutures, subdermal tissues with 4-0 PDS along the subcuticular layer. All of the incisions and skin looked intact and pink and viable. Mastisol, Steri-Strips, sterile dressing, surgical bra were placed. The patient was extubated and taken to the recovery room in stable condition.
OPERATION: Complex repair of the right lower lip.
DESCRIPTION OF OPERATION: The patient was placed in the papoose restraint. The area was cleansed with peroxide, saline, and Betadine and infiltrated with 1% lidocaine with epinephrine.
The orbicularis oris muscle was reapproximated using 5-0 Monocryl sutures followed by precise realignment of the vermilion cutaneous border using 5-0 Monocryl. The 5-0 Monocryl sutures were utilized in the vermilion portion of the lip and then 5-0 chromic along the cutaneous portion of the lip completing the complex repair, everting the edges.
Hemostasis was adequate. The area was covered with bacitracin. The child will be discharged on soft diet, avoid acidic or spicy foods, and will keep bacitracin ointment over the areas. To take amoxicillin and follow up over the next 7-10 days, to follow up for adequate scar maturation. He tolerated this well.
OPERATION: Staged breast reconstruction with expander exchange for saline implants.
ANESTHESIA: General anesthesia with LMA.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and was placed in a supine position on the operating table, whereupon all appropriate monitoring equipment was attached. At this point, general anesthesia was uneventfully instituted including LMA. Ancef 1 gram was given for prophylaxis. The entire operative site was prepped with Betadine in the usual manner, and sterile drapes were applied in the usual fashion. With excellent illumination, including lighted breast retractor and loupe magnification, the procedure was undertaken. The lateral portion of the old right incision was opened up with a #15 blade and deep resection was done with the Bovie cautery device. Towards the inframammary fold, the capsule was identified and opened. The expander was separated from the surrounding tissue and then removed uneventfully.
The pocket was examined and was unremarkable. I did open up the capsule along its entire length, except laterally, and did make a few radial releases about 1 cm interval and for just about 1 cm length along the entire inferior portion just to avoid tightness. Meticulous hemostasis was obtained. The pocket on the right side was now irrigated with saline plus Kantrex and a row of #3-0 Vicryl sutures were placed in the capsule opening to tie down after the implant was placed.
The implant had been prepared on the back table with all air evacuated and 100 mL of saline added; all saline was added from a closed system. It was now put in place and inflated up to its maximum fill volume of 240 mL.
Attention was then directed to the left side and it was done in the same fashion, although a much more aggressive capsule release was done inferiorly. I did release the capsule along the entire inferior edge and then medially just up to the superior pole. No superior release was done. Inferiorly, I did dissect along the chest wall to the preoperatively determined mark, being just about 1 cm below the present inframammary fold. Then, radial releases were made at 1 cm intervals for a distance of just about 3.5 cm to completely release the capsule.
This pocket was similarly irrigated with saline plus Kantrex and #3-0 Vicryl sutures were put in place but note that I did manipulate the lateral capsule so that it would completely cover over the now wider opening, but I did not violate the lateral aspects so that the implant did stay medial. The implant was put in place and inflated up to 240 mL. Re-inspection showed excellent projection and shape on the left side but a little bit more projection on the right. Accordingly, I did add 10 more mL to the right side, which gave an improved symmetry. I did consider dropping the volume on the left to the minimum fill volume of 230, but I was concerned that we would actually get a better aesthetic result with this overinflation on the right.
The fill valves were removed and the seal was placed. The #3-0 Vicryl sutures were tied down. An additional buried #3-0 Vicryl was placed in the subcutaneous layer before the subcuticular #4-0 Vicryl was put in place, and Steri-Strips over Mastisol were used to complete the closure. I did inspect before closure with good shape and equality seen, and this only improved once the deep tissue was brought back into position.
All layers were cleansed and light dressing was put in place with ABDs and bra. Needle and sponge counts were correct at the end of the case. The procedure being ended, anesthesia was also ended. The patient was escorted to the recovery area, having tolerated the procedure and the anesthesia in a satisfactory condition. I did speak with the patient postoperatively reviewing the operative findings and plans. Written instructions were also provided, and she does have a followup for next week.
1. Full abdominoplasty.
2. Bilateral inner thigh liposuction.
DESCRIPTION OF PROCEDURE: After identification of the patient and obtaining informed consent, she underwent the following procedure. In the preoperative holding area, the patient was marked in the presence of her husband. The patient was brought in with her typical type of underwear, bikini style, that she likes to wear. Markings were made where these normally fall on her hips, with plans to make the incision to be in an area that would be covered by her underwear.
I explained that I could not guarantee that postoperatively the incision would actually be there. This is because there are factors related to the stretch in the skin that can affect where the incision will rise or fall and so there is no way to guarantee that the scar will be completely coverable with all types of underwear. It may be visible with certain types of clothing. I also reminded her that there would be a permanent scar. The patient was marked for the contour areas of liposuctioning along the area just above the knee and the inner thigh, anteriorly along the thigh and posteriorly just below the buttock, also some liposculpture along the lateral abdomen as part of the abdominoplasty in suprapubic areas.
The patient was taken to the major operative suite, placed on the table in supine position. After induction and intubation of general anesthesia, sequential compression stockings were placed by nursing staff, and the abdomen and thighs were prepped and draped in the usual sterile fashion with Betadine scrub and paint. Surgery was begun by using 10 blade scalpel to make the abdominal incision, which went from hip to hip along the suprapubic area. Also used a 15 blade scalpel to incise around the umbilicus, elevated skin and subcutaneous tissues off the rectus muscle with electrocautery superiorly up to the level of the costal margin and xiphoid.
After completing the dissection, I injected tumescent solution laterally along the abdomen, superiorly along the suprapubic area in a small stab incision, each inner groin region, and injected liposuction tumescent solution along the inner thighs. A second and third stab incision was made along the medial and posterior thigh and just above the knee on the inner thigh of each leg. I used tumescent solution consisting of 3 liters of saline mixed with 3 cc of epinephrine, 1:1000 and 60 cc of 1% lidocaine plain. I injected a total of approximately 1500 cc of tumescent solution using approximately 650 cc in each inner thigh, 100 cc in the suprapubic area, and 200 cc equally divided along the lateral abdominal regions.
I performed liposuction with #3 and #4 liposuction cannulas from alternating directions suctioning out the deep subcutaneous fat tissue compartment, from the inner thighs, removing approximately 450 cc of liposuction aspirate from each inner thigh for a total of 900 cc. Then, proceeding to the suprapubic area, removed an additional 50 cc of supernatant fat from the suprapubic region. Then, along the lateral abdomen, on each side, removed a total of approximately 450 cc of liposuction aspirate from a total of 1500 cc of liposuctioning.
The patient was then placed in the flexed position on the operating table, confirmed, and I could resect the appropriate amount of abdominal skin, elliptically excised, using 10 blade scalpel and cautery. The weight of the tissue was approximately 795 grams. Returning to supine position, performed a repair of the diastasis of the rectus muscle inferior to the umbilicus and superior to the umbilicus with running sutures of 0 Ethibond imbricating the anterior layer of the rectus sheath. Lateral to the umbilicus, imbricated the anterior layer of the rectus sheath on each side to complete the repair of the diastasis. Then, laterally, performed an imbrication of the lateral portion of the anterior layer of the rectus sheath with running sutures of 0 Ethibond to pull on the waistline creating an internal corset.
Irrigated the abdomen with saline containing bacitracin, injected 0.25% Marcaine with epinephrine into the intercostal nerve area just below the anterior layer of the rectus sheath along the lateral border of the rectus muscle on each side for postoperative pain relief. Then, closed the abdominal layer after retroflexing on the operating table using 2-0 Vicryl sutures in Scarpa's fascia, 3-0 Vicryl sutures in subdermal tissues, and 4-0 Monocryl along the subcuticular layer.
Prior to closure, a #10 flat JP drain was placed and brought out through one of the puncture incisions in the inner groin region that was used for liposuctioning. It was placed to bulb suction. Umbilicus inset at the midline using 3-0 Vicryl sutures subdermally, 5-0 Monocryl along subcuticular layer. The liposuction port sites were closed using 4-0 Vicryl sutures subdermally and interrupted sutures of 5-0 Prolene along skin edges. The patient had nice contour of the abdomen and thighs and appeared to be symmetrical.
The areas were clean. Mastisol, Steri-Strips, and sterile dressings were placed. The patient was placed in a compression girdle and abdominal binder, placed on the hospital bed in a flexed position, extubated, and taken to the recovery room in stable condition.
1. Bilateral exchange of breast implants.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine. The breasts and abdominal regions were prepped and draped in the usual fashion with Betadine. Afterwards, 60 cc of tumescent fluid was infiltrated into the medial pectoralis muscle portions of bilateral breasts. Next, the tumescent fluid was infiltrated into the abdominal region, which was approximately 800 cc. A 15 blade was used to create an inframammary incision. This was due to the fact that the patient had previous incision at this point. Dissection was continued until the capsule of the breast implant was identified. The patient had a grade 2 to 3 bilateral breast contracture. Cautery was used to enter the capsule. The breast implants were removed. The wound was irrigated. Capsulotomy was performed in the medial anterior portion as well as the inferolateral portion. The wound was irrigated, 3-0 Vicryl sutures were placed into the fascial layer x2. The breast implants were inserted and normal saline was inflated to 450 cc bilaterally. Afterwards, the patient was sat up for evaluation of symmetry. The fill tube was withdrawn, and digital manipulation was used to ensure the placement of the nipple valve onto the breast implant. The sutures were tied. Intradermal suturing was performed with 4-0 Vicryl and a final running layer also with 4-0 Vicryl sutures.
The abdominoplasty was then performed by elevating the umbilicus on double hooks and circumscribed with a 15 blade. A 10 blade was used to make an incision from the left anterior superior iliac spine to the right ASIS. Dissection was continued beneath the Scarpa's and Camper's layers. Dissection was continued to the level of the umbilicus. The patient had sufficient lower pannus; therefore, the lower half was split between the right and the left sides. Dissection was continued around the umbilicus and to the level of the xiphoid with the assistance of Metzenbaum scissors and cautery. The skin was retracted inferiorly and excess pannus was discarded with a 10 blade. Bleeding points were cauterized. The wound was irrigated. The patient's abdominal rectus fascia was sutured in the midline with 0 Gore-Tex suture. The wound was irrigated. The Jackson-Pratt drains were placed x1, out the right inguinal region. The Scarpa's and Camper's fascial region was closed with a 2-0 PDS suture. Final running layer was closed with a 3-0 Vicryl suture interrupted and a final running layer of 4-0 Vicryl suture. The umbilicus was brought through its new point, which was at the level of the iliac crest in the midline, 3-0 Vicryl and 4-0 Vicryl sutures were used to close the intradermal suturing in a final layer with a 4-0 Vicryl suture. The patient had accessory dog-ears, which was improved with the accessory liposuction. The patient tolerated the procedure well, and the patient was then placed into a loose abdominal binder after suturing the JP in place with a 2-0 PDS suture and Steri-Strips being applied to the incision.
The patient was then placed into abdominal binder and a loose sports bra and sent to recovery room with vital signs stable.