DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right medial superior brow, 1 x 1.5 cm defect following Mohs excision of basal cell carcinoma.
POSTOPERATIVE DIAGNOSIS: Right medial superior brow, 1 x 1.5 cm defect following Mohs excision of basal cell carcinoma.
OPERATION PERFORMED: Reconstruction of right medial brow defect with immediate soft tissue expansion and complex repair.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia with LMA.
COMPLICATIONS: None apparent.
ESTIMATED BLOOD LOSS: Less than 10 mL.
DRAINS AND TUBES: None.
SPECIMEN: Excess tissue, discarded.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine position on the operating table, whereupon all appropriate monitoring equipment was attached. At this point, general anesthesia was uneventfully instituted, including with LMA placement. The area was examined, and through a 27 gauge needle, 20 mL of 1% lidocaine with 1:100,000 epinephrine was injected for hemostasis and postoperative pain relief.
The entire site was prepped with Ultradex in the usual manner, and sterile drapes were applied in the usual fashion. Note that the eyes had been lubricated before prepping and were thereafter covered with a moist saline sponge. The sponge did well to protect the eyes and probably further delayed us seeing her upper eyelid scar until after we had already done the expansion and started the complex repair while pulling on the eyebrow with Guthrie skin hooks and pulling up the tissue away from the gauze covering.
Minimal undermining was now done in the plane beneath the frontalis muscle, making a pocket along the periosteum pretty much over the whole central and right forehead. Into this pocket, a 30 mL balloon Foley was now inserted and inflated up to its 30 mL volume allowing it to sit in place for 10 minutes. This stretched the forehead tissue considerably, and after this balloon was removed, we did undermine just in the subcutaneous plane enough to allow advancement, advanced the tissue easily to the superior brow, and then removed the triangular excesses on either side to allow a smooth closure line along the upper border of the brow.
Note that the cuts that we made did come parallel to the hair follicles and we did not do any additional excision or debridement along the dermatology-created defect in order to maintain all maximum tissues. The area was irrigated, and additional hemostasis was assured with the Bovie.
The deep tissues were now closed with buried 5-0 Vicryl and the skin itself was closed with a running half-locked trailing vertical mattress suture of 6-0 monofilament. The advancement from either end with the excisions did allow a very straight line closure along the superior border of the brow, and the medial expansion of the forehead was successful in allowing us to get a very symmetrical appearance between the two brows. There undoubtedly will be some pull on the upper eyelid, but it did easily close with pressure and pretty much was identical to the left side. The area was cleansed and dressed with Polysporin ointment. Ice was applied in the recovery area. The procedure being ended, anesthesia was also ended. The patient was then escorted to the recovery area, having tolerated the procedure and the anesthesia satisfactorily.