PREOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.

POSTOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.

SURGERY PERFORMED: Left breast reconstruction with placement of subpectoral implant and pocket adjustment (extensive capsular release).

SURGEON: John Doe, MD

ANESTHESIA: General anesthesia with LMA.

COMPLICATIONS: None apparent.

ESTIMATED BLOOD LOSS: Less than 50 mL.

DRAINS AND TUBES: A 7 mm Jackson-Pratt drain.

SPECIMEN: Removed expander, discarded. Left breast implant capsule for culture and sensitivity (aerobic, anaerobic, AFB and fungal).

IMPLANT: McGhan 363LF implant with 450 cc of saline added.

INDICATIONS FOR SURGERY: The patient is a (XX)-year-old female who is status post bilateral mastectomies for cancer, reconstructed with subpectoral expanders and implants. Unfortunately, the implant on the left side had clinical infection, although no positive cultures, and had to be removed.

The tissue has now settled down and now for replantation with the major concern being additional infection and also scar. Options considered including replacement of an expander or using a Mentor adjustable implant. However, concern would be that if we do not get adequate reconstruction, the scar tissue is going to be the major limiting factor and would need additional vital tissue, latissimus flap, to permit adequate reconstruction.

Given the risk of infection, we planned to irrigate with both Ancef and kanamycin as bacitracin was not available. In addition, given preoperative Timentin, and we will use Augmentin postoperatively. A drain will be placed.

DESCRIPTION OF SURGERY: The patient was taken to the operating room for left breast reconstruction and was placed in the supine position on the operating table whereupon all appropriate monitoring equipments were attached. At this point, general anesthesia with LMA was uneventfully introduced. Timentin was given intravenously.

The patient had been marked in the preoperative holding area in a sitting position as to the planned lines of the pocket creation and these marks of course were left in place. The entire operative site was then 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 left breast reconstruction was undertaken.

The previous left lateral incision just above the inframammary fold was used, and deeper dissection was done with a Bovie cautery device maintaining meticulous hemostasis at this point and throughout the entire procedure. There was some vigorous bleeding along some of the scar tissues, but it was easily controlled with the cautery.

We did dissect underneath the pectoralis and soon came to the previous pocket. This was then enlarged to the marks coming to the lateral border of the sternum, the inframammary fold, anterior axillary line, and then superiorly as well. The periphery being well open, the overlying scar tissue of the capsule was now opened with moldable “postage stamp” dissections until by palpation it was completely released to allow good expansion over the implant.

The pocket was again examined and a portion of the lateral pocket along the chest wall was excised, cut into small sections and sent for culture. No purulence, unhealthy tissue, masses or any other abnormalities were seen beyond the scar.

The #3-0 Vicryl sutures were placed along the capsular opening at the incision and left long to tie down over the implant once placed.

The pocket was copiously irrigated with saline plus Kantrex and Ancef after a 7 mm Jackson-Pratt drain had been placed through the previous stab wound laterally inferiorly and sutured to the skin with #3-0 Vicryl.

Re-inspection was unremarkable, no active bleeding.

The implant was prepared on the back table with all air evacuated and 50 cc of saline added. The implant was now put in position and inflated up to 500 cc, the volume of the right side, and then after about 2-1/2 minutes, it was backed down to 450 cc which had been the equalizing point earlier. That seemed to give a good volume match to the right side but again concern was related to the scar and how well the tissue will re-drape to allow good breast reconstruction.

The fill valve was removed and the seal placed. The #3-0 Vicryl sutures were tied down. Additionally, a #3-0 Vicryl was placed to the subcutaneous layer and then a subcuticular #4-0 Vicryl. Steri-Strips over Mastisol completed the closure.

The entire area was cleansed and dressed with ABDs and bra. No abnormalities were seen in the skin, except for scars.

The left breast reconstruction being done, anesthesia was also ended. The patient was then escorted to the recovery area having tolerated the procedure and the anesthesia in a satisfactory condition. Written instructions were provided. She already has a prescription for Augmentin and Lortab. Followup has been arranged for next week. The patient was specifically instructed to call if there are any questions or problems.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Dermatochalasis of the abdomen and hips and ptosis of the breast.

POSTOPERATIVE DIAGNOSIS:  Dermatochalasis of the abdomen and hips and ptosis of the breast.

OPERATIONS PERFORMED:

1.  Circumferential abdominoplasty.

2.  Bilateral breast mastopexy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  With the patient positioned in the sitting and the standing position preoperatively, preoperative markings were performed for circumferential abdominoplasty and bilateral breast mastopexy.

The patient was taken to the operating room where general endotracheal anesthesia was obtained. Thromboguards were placed on the lower extremities, and the patient was then turned to the prone position on the operating room table.

The patient’s arms were padded at the anatomic position on arm boards, and she was placed on chest rolls. The patient’s knees were protected with gel pads and attention was turned to prepping the lower back and buttocks region with Betadine gel and draping in a sterile manner.

Attention was then turned to the previously marked areas of lower back, where the skin was incised with a 10 blade and carried to the subcutaneous tissue to the lumbar fascia and gluteal fascia.

Once this was completed, for approximately 8 cm, the gluteal skin was undermined for advancement to the previously marked areas where cross-hatching had been done.

Once this was completed, the complete strip of the lower back and upper buttocks was removed and hemostasis was obtained.

The wound was irrigated with Ancef solution, and attention was turned to advancement and closure of the skin flaps using 0 Nurolon in the deep Scarpa’s fascia and lumbar fascial region, 2-0 Vicryl in the deep dermis, 3-0 Vicryl in the intermediate dermis, and subcuticular running 4-0 Monocryl.

After these areas were completed, all areas were cleansed. Xeroform gauze was applied. A Coverlet dressing was applied, and the patient was then undraped, cleansed, returned to her bed in supine position and then repositioned on the operating room table in the supine position.

The patient’s arms were secured to the arm boards with padded blankets and Ace wraps. Thromboguards were re-placed on the lower extremities. Foley catheter was placed in the bladder. Perineum was prepared by shaving.

Attention was then turned to prepping the chest and abdomen with Betadine gel and draping in a sterile manner. Attention was first turned to the lower abdominal region, where the skin was incised with 10 blade and carried down to the level of the rectus fascia.

Superior dissection was carried to the level of the umbilicus. The umbilicus was freed from the overlying skin and then further dissection was carried to the level of the xiphoid.

A high-tension abdominoplasty was performed by undermining the flanks with a sponge stick and hemostasis was obtained. Wound was then irrigated with Ancef solution. Two Blake drains were then placed through either side of the mons pubis and secured with 3-0 Vicryl suture.

One leg was laid into the area of the anterior iliac crest. The other was laid superiorly along the paramedian portion of the abdomen. Diastasis of the abdomen was extremely minimal, so no muscle repair was required.

Attention was now turned to placing the patient in the general jackknife position. Excessive skin was marked for resection and completely removed, removing a total of 29 cm of skin from the lower abdomen. Once this was completed, hemostasis was obtained.

Attention was turned to closure using 0 Vicryl in the deep tissue, 3-0 Vicryl in the deep dermis, and subcuticular running 4-0 Monocryl. Umbilicus had been marked and brought through a transverse stab wound in the abdomen and was then secured with 3-0 Vicryl and 5-0 nylon.

The patient tolerated that portion of the procedure extremely well.

All areas were cleansed. Xeroform gauze 2 x 2 and full length Steri-Strips were applied to the umbilical region, and attention was then turned to covering the abdomen with a sterile sheet.

Attention was then turned to the area of the breast. The breast area was marked, and attention was turned to injecting the incision lines with dilute solution of adrenaline and Ringer’s lactate.

After this was completed and hemostasis was obtained as evidenced by blanching of the skin, attention was turned to de-epithelializing the entire inferior quadrant of the breast skin, and the small triangle in the lateral and medial aspects of the breast were resected for adequate closure.

After this was completed, the medial and lateral breast flaps were elevated at the level of the pectoral fascia. Hemostasis was obtained.

The wounds were irrigated with Ancef solution. The inferior pedicle of the breast was then advanced superiorly and the medial and lateral breast flaps were closed over the top of the inferior pedicle.

Attention was then turned to formal closure using 3-0 Vicryl in the deep tissue and subcuticular running 4-0 Monocryl after bringing the nipple areolar complex through at 5 cm above the inframammary crease.

The patient tolerated the procedure well. Nipple circulation looked excellent at the end of the procedure. All areas were cleansed. Half-inch Steri-Strip and Xeroform gauze were applied to the incision lines.

The patient was then undraped, completely cleansed, dried, and sterile dressings were applied. The patient was then placed in a compression garment and a postoperative bra. She tolerated circumferential abdominoplasty and bilateral breast mastopexy procedure well.

Estimated blood loss was 150 to 200 mL. The patient received 2000 mL of crystalloids. Urinary output was excellent. The patient returned to the recovery room in good condition where she will be admitted for 23-hour observation.

The post Circumferential Abdominoplasty Medical Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

ALLERGIES: She has no known drug allergies.

SOCIAL HISTORY: She is a nonsmoker.

EXAMINATION: The patient is an attractive woman, looking younger than her stated age. The patient has some mild medial lower lid bag with excellent tone of the eyelid skin. The patient has a mild tear trough present and a slightly flat malar eminence. Nasolabial folds are very mild. Cranial nerve VII is intact and symmetrical bilaterally. When the patient closes her eyes, a wide upper eyelid scar can be noted bilaterally. Lower lid snap-back is excellent.

ASSESSMENT: A patient with mild tear troughs and nasolabial creases. Could benefit from filler or could consider transconjunctival lower blepharoplasty.

PLAN: We discussed with the patient that we think that both the areas that she expresses concern about could be treated by fillers. As a matter of fact, the same filler could be used for both sites.

Our recommendation would be to use Belotero along the tear troughs to fill in the trough, which occurs as the lower lid fat protrudes against the orbital septum and creates a valley at the site where the septum attaches the orbital rim and then the cheek begins.

We discussed this is not a permanent fix for this area, and a filler in this area would probably last about nine months. She could consider removal of the fat with a transconjunctival blepharoplasty. This would involve surgery under anesthesia and probably involve about a two-week recovery period during which time she probably would want to abstain from work.

We discussed that the nasolabial fold is mild and could be filled with the same filler as the tear troughs. One other area where she could consider, but it is certainly not mandatory, is whether or not she wants to fill in the malar area. There is a separation between the middle and medial fat pad with some malar flattening in the area. When you follow the tear troughs, your eye does continue along the cheek and filling this in could give her a little bit more of a youthful appearance. The patient is not interested in doing that today.

We discussed that both surgery and fillers do have risks involved. Both involve risk of injury to the eye and vision as well as blurry vision, double vision or loss of vision.

Bruising, bleeding and swelling are also possibilities as well as dissatisfaction with the result. The patient has not had aspirin, ibuprofen or vitamin E recently. We do not think that she has a higher risk of bleeding or bruising than anyone else. The patient and I reviewed the informed consent form for dermal fillers, and the patient understands. The patient has had the opportunity to ask all questions and consented to proceed.

PROCEDURE: A photograph of the patient was taken, and the patient’s skin was anesthetized with Quadri-Caine ointment. This was then wiped clean from the skin and the skin prepped with alcohol.

Belotero was then infiltrated along the tear trough bilaterally taking great care to avoid intraocular injury and injection into the fat pads around the eye. 0.2 cc was delivered to each site.

After correction of both tear troughs, the patient had an opportunity to view the result before beginning the next area. The nasolabial crease was then treated with superficial infiltration of Belotero into the nasolabial fold bilaterally.

Additional treatment was performed at the left tear trough as one area did not appear to be completely corrected. The patient tolerated the procedure well. Ice was applied.

She will return p.r.n. However, she would like to return in two weeks for a recheck. I am more than happy to see her at that point. The patient has no further questions.

Cosmetic Surgery Medical Transcription Sample Report #2

HISTORY: The patient is a (XX)-year-old woman who comes to see us today in cosmetic visit to discuss a mommy makeover. She reports she is on her third consultation with a plastic surgeon. She is unhappy with the appearance of her abdomen after her children. She knows she has a muscle separation but recently learned that she also has an umbilical hernia.

Her first doctor told her that she would not have a belly button after abdominoplasty, and she did not feel like she had a good rapport with the second plastic surgeon that she saw. She is near her goal weight, within 5 pounds, and just wants to look better in clothing.

She wears a 34 C cup bra and thinks she might be okay going a cup size larger. She complains of being deflated and not full. She wants to fill out her skin more. She dislikes that when she bends forward, her skin appears to hang.

She has no first-degree relatives with breast cancer; however, she has a paternal grandmother with postmenopausal breast cancer and a maternal great aunt, who has breast cancer, unknown at what time of her life.

She has no personal history of any breast disease. She is G2, P2, and breastfed both her children, who are now aged 6 and 5 years; these were delivered by normal spontaneous vaginal delivery.

PAST MEDICAL HISTORY: Medical history includes scoliosis, which is fairly significant and acne.

MEDICATIONS: Minocin.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: She is a nonsmoker and no smokers in her home. She does not drink and does not use drugs. She has a supportive husband.

EXAMINATION: The examination reveals that the patient stands 5 feet 5 inches tall. She weighs 150 pounds. Examination of the breasts revealed pseudoptosis bilaterally. It should be noted that her scoliosis causes a noticeable asymmetry of both her chest and her abdomen. Her right shoulder protrudes forward and is somewhat higher than her left.

In addition, her left breast is fuller than her right and lower than the right side. Examination of the breasts revealed no masses or lymphadenopathy. Nipple sensation is intact. No nipple discharge is noted. The breast tissue is fibrocystic with a loose skin envelope. Stretch marks are noted.

Sternal notch to nipple distance is 19.5 cm on the right and 20.5 cm on the left. Midclavicular to nipple distance is 20.5 cm on the right and 21.5 cm on the left. Inframammary to nipple distance was not measured. Base diameter is 13 cm on the right and 12 cm on the left.

Examination of the abdomen revealed significant stretch marks present, both below and above the umbilicus.

Protrusion is noted in the area of the umbilicus with a protruding umbilical hernia. There is significant rectus diastasis noted in the periumbilical area as well, below and above the umbilicus. The skin quality is thin at the abdomen as well. The patient appears to have a somewhat short torso.

ASSESSMENT: Relatively micromastia and abdominal wall laxity with umbilical hernia. Could benefit from breast augmentation.

PLAN: We discussed with the patient that we think she would be a good candidate for surgery with some caveats. We discussed with her that because of her skeletal asymmetry, she will likely have an asymmetry at her abdomen as well as at her breasts.

We would try to make the breast volume more similar. She does have an asymmetry of nipple height, which will persist unless we specifically address this at surgery. The patient has been used to this asymmetry, and it does not bother her.

We reviewed the PowerPoint presentation regarding breast augmentation and the difference between saline and silicone breast implants.

Our recommendation for her would be a silicone submuscular implant placed through an inframammary fold incision. We discussed the history of silicone implants, the moratorium, the construction, silent rupture, monitoring of the implant, and why it is beneficial to place the implant in the submuscular position, risks of capsular contracture, rippling and wrinkling, implant displacement, infection requiring removal, sensory changes of the nipple, dissatisfaction with the result, inability to guarantee a bra cup size, pain, infection, bleeding, damage to neighboring structures and the need for further operations.

The patient and I discussed that it is likely that an asymmetrical fill may be required with a larger implant on the smaller side to make the volume of her breast look more even, but an asymmetry will still persist.

Regarding the abdomen, we discussed that a general surgeon will be needed to do an umbilical hernia repair concurrently with the abdominoplasty. We drew for her a low-lying abdominal incision. Dissection will be taken up to the umbilicus and around the umbilicus. We discussed that she has a high risk of umbilical healing difficulties because the stalk will have less of a blood supply.

We would avoid being too aggressive with contouring of the umbilicus to allow preservation of the tissue there. It is possible to go back at a later time and make the umbilicus better. We would avoid being too aggressive and risk umbilical necrosis. Regardless, it is possible that umbilical necrosis could occur. If this happens, she could have umbilical reconstruction, but that may result in additional scarring.

We discussed that we cannot remove all her stretch marks. The muscle will be repaired in the midline after umbilical hernia repair. We would put her in a flexed position and excise the excess breast tissue. She will remain in a flexed position approximately 7 to 10 days. Drains will be placed, which will be removed somewhere in the neighborhood of approximately 2 weeks after surgery.

The patient will need to avoid heavy lifting and strenuous activity for 6 weeks and do princess treatment or minimal physical activity for the first 2 weeks after surgery. She would need to outsource child care and housework.

The patient and I discussed that the scar is likely to be asymmetric and slightly uneven due to her stretch marks and also her scoliosis, but we would try to make it as even as possible. We discussed the risk of dog ears, sensory changes of the skin of the abdomen, DVT, PE, seroma and again dissatisfaction with result.

The patient and I discussed having overnight stay in the hospital. She had an opportunity to have all her questions answered. If she is interested in scheduling, she will come back for a preoperative visit.

Cosmetic Surgery Medical Transcription Sample Report #3

HISTORY: A (XX)-year-old African American female presents in cosmetic visit for concerns regarding the cosmetic appearance of her face. She complains about lower face and neck laxity. She complains about wrinkles of her lower face, near her marionette lines, as well as nasolabial folds. However, her main concern is lower face and neck laxity and wrinkling of her neck region. She also initially inquired about upper and lower blepharoplasty, but I informed her that she is not a candidate for either of these.

EXAMINATION: Face:  The patient has facial aging significantly less than her stated age. There is mild brow ptosis and moderate dermatochalasis of bilateral upper eyelids. Her brows, however, are very dynamic and the dermatochalasis disappears quite often due to her dynamic elevating eyebrows. There is no significant fat herniation of the lower eyelids, but there is some wrinkling of the lower eyelid skin consistent with her age. There is moderate upper midface volume loss with some fullness of her lower midface, nasolabial folds, and marionette lines. There is severe lower face and neck laxity with platysmal banding. However, for her age, the laxity is not severe relatively.

RECOMMENDATION: Lower facelift: I emphasized to the patient that her aging is significantly less than her stated age. She does have some significant laxity that can be improved by a lower facelift, but I emphasized to her the scars associated with the procedure and the fact that the scars are permanent, lengthy and can hypertrophy. I informed her that overall her improvements will be significant, but she is at a definite higher risk of a darker and a thicker scar due to her skin color. The big question is whether the trade-off of a tighter jawline and neckline are worth the scarring. I informed her that she is even at risk of possible keloids. We also discussed other possible complications, including bleeding, infection, seroma, DVT and pulmonary embolism. The patient states she is going to consider her options here and will let us know what she decides.

Cosmetic Surgery Medical Transcription Sample Report #4

HISTORY:  The patient is a (XX)-year-old woman who comes today in cosmetic visit for Botox to the glabella. She has had this performed in the past and has had no untoward effects with Botox in the past. The patient last had treatment in June of (XXXX).

PAST MEDICAL HISTORY: The patient has medical history significant for hypertension and adrenal insufficiency as well as hypothyroidism.

MEDICATIONS: Include atenolol, Norvasc, hydrocortisone, natural thyroid and an inhaler.

ALLERGIES: NKDA.

EXAMINATION: Examination reveals that the patient has a large, slightly asymmetric glabella with a wider corrugator muscle on the right side than the left. There is full activity at both the corrugator and procerus. No lid ptosis is noted.

ASSESSMENT: The patient with mild signs of facial aging. Could benefit from Botox treatment at the glabella.

PLAN: Risks were reviewed, including pain and swelling at the injection site, headache, flu-like symptoms, lid lag, which can be treated with over-the-counter drops and not expected to last as long as the Botox treatment itself, dry eye, damage to deeper structures, ptosis of the eyelid, asymmetry, pain, distant reactions, and dissatisfaction with the result. The patient is interested in proceeding.

PROCEDURE: The skin was cleansed with alcohol. Botox was injected into the procerus muscle using 5 units, the medial corrugator head using 6.25 units bilaterally, and the corrugator tail using 2.5 units bilaterally. The patient was reminded that Botox will take up to two weeks to work. She can come back in two weeks if needed for a touch-up treatment.

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Plastic Surgery Medical Transcription Operative Sample Reports #1

OPERATIONS PERFORMED:
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.

Plastic Surgery Medical Transcription Operative Sample Reports #2

PREOPERATIVE DIAGNOSIS: Abdominal lipodystrophy.

POSTOPERATIVE DIAGNOSIS: Abdominal lipodystrophy.

OPERATION: Abdominoplasty.

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.

Plastic Surgery Medical Transcription Operative Sample Reports #3

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.

Plastic Surgery Medical Transcription Operative Sample Reports #4

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.

Plastic Surgery Medical Transcription Operative Sample Reports #5

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.

Plastic Surgery Medical Transcription Operative Sample Reports #6

OPERATIONS:
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.

Plastic Surgery Medical Transcription Operative Sample Reports #7

OPERATIONS:
1. Bilateral exchange of breast implants.
2. Abdominoplasty.

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.

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