HISTORY: The patient is a (XX)-year-old woman who is coming to see us today in cosmetic visit to discuss options for improvement of her eye bags and nasolabial folds. The patient would like to stay with noninvasive treatments and not have to have surgery if possible. She complains that the eye bags have been bothersome for the past five years. Her nasolabial fold has been bothering her for the last 12 months. She has had only one prior cosmetic procedure. She had upper eyelid surgery at age (XX). The patient takes over-the-counter Benadryl to help sleep.
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.
