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.

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PREOPERATIVE DIAGNOSIS:  Open wound, left dorsolateral aspect of the foot.

POSTOPERATIVE DIAGNOSIS:  Open wound, left dorsolateral aspect of the foot.

PROCEDURE PERFORMED:  Split-thickness skin graft to the open wound from left lateral thigh; size of the graft is 5 x 5 cm.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  10 mL.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old Hispanic male who was involved in a motor vehicle accident and sustained an open wound on the dorsolateral aspect of the left foot. The patient also has a cuboid fracture. He was doing wet-to-dry dressing, and he was noted to have about 4 x 4 cm open wound with red granulation tissue. Decision was made to proceed with skin graft of that area.

DESCRIPTION OF PROCEDURE:  The patient was given 1 g of Ancef in the preop area. The patient was brought to the operating room and placed in the supine position. The left lower extremity was then prepped and draped in regular sterile routine fashion.

The open area, which was about 4 x 4 cm, was clean and healthy with red granulation tissue. The edges were refreshened. The area was irrigated copiously with normal saline to be prepared for a skin graft. The lateral upper thigh was then cleaned with mineral oil. The dermatome was set up for 0.015 inches thick. About 5 x 5 cm split-thickness skin graft was taken from the left upper thigh.

The graft was then fenestrated with the 15 blade. The graft was fit on the open wound and was secured with 3-0 nylon. The Adaptic was put over the graft and a ball of cotton moistened with normal saline was placed over the Adaptic and was secured with tail of the 3-0 nylon. Dressing was then applied involving 4 x 4 over the cotton ball and sterile Webril. For the donor site, it was dressed with epinephrine mixed in gauze. The 4 x 4 and Ace wrap were placed.

The patient tolerated the procedure well and was taken to recovery in stable condition. A splint was applied to the left foot.

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PREOPERATIVE DIAGNOSIS: Skin cancer of the nose.

POSTOPERATIVE DIAGNOSIS: Skin cancer of the nose.

OPERATION PERFORMED:
1.  Wide local excision of 1 cm nasal tip skin cancer.
2.  Banner local flap for closure.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  Monitored anesthesia care with IV sedation and local.

ANESTHESIOLOGIST:  Jane Doe, MD

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old female who presented with biopsy-proven skin cancer of the nasal tip. Because of its location and need for frozen sections, the patient was brought to the operating table where Pathology could give us frozen section results.

OPERATIVE FINDINGS:  Free margins with residual tumor. A second, extended margin of the deep layer was taken, which showed free margins as well.

DESCRIPTION OF OPERATION:  After obtaining written consent, which included but was not limited to infection, bleeding, scars, deformity of the nose, loss of part or all of the skin flaps, recurrence of tumor, and need for further surgical revisions, the patient understood, and all of her questions were answered. The patient gave full consent to proceed.

The patient was previously marked at the dermatologist’s office where biopsy had been taken. She was brought to the operating table and examined under loupe magnification. This indeed showed residual area of biopsy site. This was infiltrated with 1% lidocaine with epinephrine after induction with IV sedation with monitored anesthesia care and monitoring. She was then prepped and draped in the usual sterile fashion. Wide local excision of a 1 cm area was excised and sent to Pathology. The margins showed free tumor; however, there were some close cells deep to the deep margin. A second extended margin of deep tissue was taken, which showed no tumor.

A local banner flap was then elevated and placed into the defect. It was inset with interrupted 5-0 and 6-0 nylon sutures. Undermining was performed to allow easy closure of the donor site. Dressings were applied. The patient was brought to the recovery room in stable condition.

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PREOPERATIVE DIAGNOSIS: Absent breasts, bilateral following mastectomies.

POSTOPERATIVE DIAGNOSIS: Absent breast, bilateral, following mastectomies.

OPERATION PERFORMED: Bilateral breast reconstruction with TRAM flaps.

SURGEON: John Doe, MD

ANESTHESIA: General.

INDICATION FOR OPERATION: This (XX)-year-old Hispanic female has previously undergone double mastectomies for cancer. She is free of disease and is here for reconstruction.

FINDINGS AND DESCRIPTION OF OPERATION: The patient’s chest wall was marked with her in a sitting position in the holding area. She was then brought to the operating room and placed on the OR table in supine position. General anesthesia was induced. Foley catheter was placed in the bladder, and sequential compression devices were placed in the lower extremities.

An incision was made in the left and right sides of the anterior chest wall, and skin flaps were elevated. Elevation was made at the level superficial to each pectoralis major muscle. A periumbilical incision was then made with #15 blade, and the umbilicus was dissected from surrounding soft tissue with Metzenbaum scissors. A 10 blade was then used to make a long transverse abdominal wall incision at the level of the umbilicus. Electrocautery dissection was carried down to the anterior rectus sheath, and a large apron of skin fat and fascia was elevated. A subfascial tunnel was created to the pockets created on either side of the anterior chest wall.

A 10 blade was then used to make a longitudinal incision over the anterior rectus sheath, one incision directly over each rectus abdominis muscle. Electrocautery was used to dissect each muscle from its investing fascia. Once each muscle was completely freed from investing fascia, a long transverse incision was made in the lower abdominal wall, thereby completing the skin paddle. Dissection was carried down to the level of the anterior rectus sheath. The lateral aspects of the large transversely oriented paddle were then elevated with electrocautery until the mid level of each muscle was reached. The fascial cuts were completed with a 10 blade, and each inferior epigastric artery and its accompanying veins were isolated and ligated with 2-0 silk suture. The insertion of each rectus abdominis muscle was then divided with electrocautery, and the flap was then completely freed from investing fascia. A central strip of rectus abdominis muscle fascia was preserved to help facilitate abdominal wall reconstruction. The flap was then bisected in the midline, thereby creating two separate breasts flaps. Each was gently passed through its subfascial tunnel to the chest wall.

The flaps were then appropriately trimmed and de-epithelialized. Each was then sutured in place over a 7 mm flat JP drain using 3-0 Vicryl and 4-0 PDS in the deep dermal and subcuticular dermal layers respectively. The abdominal wall was then reconstructed in this patient using large pieces of AlloDerm. The anterior rectus sheath was repaired in the upper abdominal wall using #1 Prolene suture. When the lower abdominal wall area was reached, where there was missing fascia from flap transfer, AlloDerm was used for the repair of the fascia. This was secured in placed with Prolene suture.

The patient’s bed was placed in extremely flexed position with head of bed elevated, and flap closure was completed using 2-0 Vicryl in Scarpa fascia, 3-0 Vicryl in the deep dermal layer and 4-0 PDS in subcuticular dermal layer. The umbilicus was brought out the central portion of the abdominal wall through the small transverse incision, and the umbilicus was anchored to surrounding skin using 3-0 Vicryl in the dermal layer and 5-0 nylon in the epidermis. Two Jackson-Pratt drains were placed in the abdominal wall prior to closure and brought out the suprapubic area through stab incisions. Once closure was completed, the patient was transferred very carefully to her hospital bed, wearing an abdominal binder and a surgical bra. Estimated blood loss was 300 mL. No complications.

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PREOPERATIVE DIAGNOSIS: Right breast implant malposition.

POSTOPERATIVE DIAGNOSIS: Right breast implant malposition.

OPERATION PERFORMED:
1. Adjustment, right breast implant.
2. Right crescent mastopexy.

SURGEON: John Doe, MD

ANESTHESIA: General.

INDICATION FOR OPERATION: This (XX)-year-old Hispanic female is status post bilateral breast augmentation. She has had lateral displacement of her right breast implant and is here for adjustment of that breast implant pocket.

FINDINGS AND DESCRIPTION OF OPERATION: The patient’s right breast was marked with her in a sitting position in the holding area. She was then brought to the operating room and placed on the OR table in supine position. General anesthesia was induced, and the entire anterior chest wall was prepped and draped in an aseptic fashion.

An incision was made in the right breast inframammary crease utilizing the old operative scar. Electrocautery dissection was carried down to the pocket. The patient’s saline implant was removed and set aside to be replaced later. A capsulorrhaphy was now performed on the lateral aspect of the breast pocket using 2-0 Ethibond sutures. Initially, electrocautery was used to mark the lateralmost aspect of the right breast pocket. Then 2-0 Ethibond sutures were used to close in that lateral aspect of the pocket using interrupted suture technique. The implant was then replaced, and the patient was placed in a sitting position and was found to have much improvement in the positioning of her implant. A layered closure was performed here using 3-0 Vicryl in the deep tissue layer, 4-0 Vicryl in the deep dermal layer and 5-0 PDS in subcuticular dermal layer.

Attention was then turned to right nipple-areolar complex. A right crescent mastopexy was performed by excising a small portion of right breast skin as marked. Undermining was performed with electrocautery, and a layered closure was performed here using 4-0 Vicryl on the deep dermal layer and 5-0 PDS in the subcuticular dermal layer. Benzoin and Steri-Strips were applied at this point to both wounds, and the patient was awoken from anesthesia and transferred to the PACU in stable condition. There were no complications.

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PREOPERATIVE DIAGNOSIS:  Large nasal hump with long nasal tip and wide nasal bone.

POSTOPERATIVE DIAGNOSIS:  Large nasal hump with long nasal tip and wide nasal bone.

OPERATION PERFORMED:  Rhinoplasty.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

POSTOPERATIVE CONDITION:  Good.

DESCRIPTION OF OPERATION:  After informed consent, the patient was taken to the operating room. General endotracheal anesthesia was performed without difficulty. Antithrombotic devices were put on both lower extremities, and the patient’s entire face was prepped and draped in the standard sterile fashion. The patient’s nasal hairs were trimmed, and her inner nose was also prepped with Betadine solution.

An incision was made at the narrow portion of her columella. The incision followed inward into the nasal mucosa and then followed into a marginal incision. The nasal skin was elevated up off the cartilage where good exposure of the lower lateral and upper lateral cartilages was noted. Using a Freer elevator, the skin was elevated up off the nasal dorsum and nasal bones. At this point, the lower lateral cartilage was taken down leaving 4 mm of lower lateral cartilages, both sides. Using an osteotome, the nasal bone was taken down, and using a 15 blade, the cartilaginous portion of the septum was also sharply shaved down as well to give her a nice straight dorsum. At this point, osteotomies were done low to high. The skin was placed back over her nose, and it appeared that she had a nice result. The patient’s nasal hump was taken down and her tip looked good.

The incision line was closed using 6-0 nylon in the skin and 4-0 chromics in the nasal mucosa. Steri-Strips were applied and then a nasal splint. The patient tolerated the procedure well and left the operating room in good condition.

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PREOPERATIVE DIAGNOSES:
1.  Absent left breast following mastectomy.
2.  Right breast macromastia.

POSTOPERATIVE DIAGNOSES:
1.  Absent left breast following mastectomy.
2.  Right breast macromastia.

OPERATION PERFORMED:
1.  Left breast nipple-areolar reconstruction.
2.  Right breast reduction for symmetry.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, CST

ANESTHESIA:  General.

INDICATION FOR OPERATION:  This (XX)-year-old Hispanic female is status post left modified radical mastectomy for cancer. The patient is here for the above procedures.

DESCRIPTION OF OPERATION:  The patient’s left breast mound and right breast were marked with her in a sitting position in the holding area. She was brought to the OR and placed on the OR table in supine position. General anesthesia was induced, and the entire anterior chest wall was prepped and draped in aseptic fashion.

The right breast was reduced using a Wise pattern. A total of 150 grams of tissue was resected from the right breast, primarily from the lateral aspect but somewhat to a lesser extent from the medial aspect inferiorly. Breast flaps were elevated, and the nipple-areolar complex was preserved on a central pedicle. The breast flaps were elevated and wrapped around the remaining breast tissue with a 10 mm flat Jackson-Pratt drain placed within the breast tissue prior to closure. Extensive liposuction of the lateral aspect of the breast was performed using a Mentor liposuction machine. Marcaine 0.25% with epinephrine was infiltrated into the lateral aspect of the breast or essentially the fat in the axillary area prior to liposuction of that area. Total volume tissue liposuction was 500 mL.

A layered closure was performed using 2 and 3-0 Vicryl in the deep dermal layer with 4 and 5-0 PDS in subcuticular dermal layer. A portion of skin harvested from the right breast was used for the nipple-areolar reconstruction on the left side. A skate flap was then designed and executed on the left breast mound in the area marked. A 4-0 Vicryl and 5-0 plain suture were used to elevate the nipple flap and secure it in place. The skin graft harvested from the right breast was then appropriately trimmed and was secured around and over the nipple flap using 4-0 nylon and 5-0 plain suture.

A small amount of liposuction was performed on the left lateral axillary area. A limited dermolipectomy was performed in the left axillary area, and the resulting wound was closed with 3-0 Vicryl and 4-0 PDS. At this point, benzoin and Steri-Strips were applied to all wounds, and the patient was awoken from anesthesia and transferred to the PACU in stable condition. Estimated blood loss was 100 mL. No complications.

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PREOPERATIVE DIAGNOSES:
1.  Blepharochalasis.
2.  Brow ptosis.

POSTOPERATIVE DIAGNOSES:
1.  Blepharochalasis.
2.  Brow ptosis.

OPERATION PERFORMED:
1.  Bilateral upper blepharoplasties.
2.  Bilateral lower blepharoplasties.
3.  Contour Thread brow lift, bilateral.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  This (XX)-year-old Hispanic female is here for elective blepharoplasty surgery along with Contour Thread lift of each brow.

OPERATIVE FINDINGS AND DESCRIPTION OF OPERATION:  The patient’s upper lids were marked and turned in sitting position in the holding area. She was brought to the OR and placed on the OR table in the supine position. General anesthesia was induced. The entire face and scalp were prepped and draped in an aseptic fashion. Lidocaine 1% with epinephrine was infiltrated into the upper and lower eyelids. A small amount of same local was infiltrated into the frontal scalp as marked.

A 15 blade was used to excise excess skin from each upper eyelid as marked. A strip of orbicularis oculi muscle was resected from each upper eyelid, thereby opening each orbital septum. Excess fat from the medial and central compartments was bipolar cauterized and resected. Hemostasis was achieved in each upper lid using bipolar cautery, and 6-0 Prolene was used to close each upper eyelid incision.

A subciliary incision was then made in each lower eyelid using a 15 blade. Skin muscle flap was elevated from each lower lid, thereby opening each orbital septum. Excess fat from the medial, central, and lateral compartments was bipolar cauterized and resected. The leading edge of each lower lid was then resected, removing excess skin and muscle appropriately. Bipolar cautery was used again for hemostasis, and 6-0 Prolene suture was used to close each lower eyelid wound.

Attention was turned to each brow. Four Contour Threads were used to elevate each brows, two per brow. The threads were inserted appropriately from small incisions made in the bitemporal scalp. On each side, the threads were sutured to each other at the level of the scalp incision, and the threads were brought out below each brow appropriately, cutting off each trocar after the threads were passed. With the threads in proper position, a thumb was used to gently massage each forehead in a cephalad direction, until each brow was appropriately elevated. The right threads had to be repeated twice to obtain symmetry, but ultimately, symmetry was achieved. At this point, the patient had a nice improvement with elevation of the lateral brows. Ice, saline, gauze, sponges were applied to the eyes after application of ophthalmic antibiotic ointment. At this point, the patient was awoken from anesthesia and transferred to the PACU in stable condition. No complications.

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PREOPERATIVE DIAGNOSIS:  Crush avulsion, near amputation, right upper extremity through the elbow joint.

POSTOPERATIVE DIAGNOSIS:  Crush avulsion, near amputation, right upper extremity through the elbow joint.

OPERATION PERFORMED:  Revascularization, right upper extremity, with microvascular repair, brachial artery and venae comitantes.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  100 mL.

COMPLICATIONS:  None apparent.

DISPOSITION:  To recovery in stable condition.

INDICATION FOR OPERATION:  The patient presented to the emergency room following a work-related crush injury to his right upper extremity that resulted in an open dislocation of the elbow and disruption of the brachial artery and vascular supply to the right hand. He appeared to have some intact ulnar sensation in the emergency room. He was taken to the operating room for emergency exploration and repair. There were no other apparent major injuries.

DESCRIPTION OF OPERATION:  After induction of general anesthesia, the right upper extremity was cleaned of gross debris, painted, and then draped in a sterile manner with the donor on the right leg just for grafts, if necessary. Six liters of saline was used to Pulsavac the wound. The neurovascular structures were identified and protected, and the skin and muscle were debrided of all questionable nonviable tissue.

Volar forearm fasciotomies were performed. We identified that all the radial, median, and ulnar nerves were intact but contused and stretched. The brachial artery and venae comitantes were completely disrupted. There was an area where the periosteum was stripped for the distal 4-6 cm of the humerus with the elbow joint completely disrupted and the cartilage of the humerus eburnated. We performed this identification, exploration with orthopedic service and Dr. (XX). Dr. (XX) then proceeded to shorten the humerus and perform an elbow fusion with reconstruction plates.

Following this stability, we examined the radial artery and veins under magnification and found them to be satisfactory for primary repair. We established good inflow and then under the operating room microscope performed an end-to-end coaptation of the brachial artery with interrupted 8-0 Ethilon. We released the clamps. The warm ischemia time was approximately seven hours. This was seven hours from the date of the reported injury.

The hand pinked up immediately, and there was never a subsequent problem with the arterial anastomosis. We identified appropriate venae comitantes and then performed an end-to-end coaptation with no tension with one of the larger venae comitantes. The contralateral one was ligated, several other veins were ligated. The nerves were freed so that they were not in contact with the bone or reconstruction plate and were well covered by the arm and forearm musculature. The pedicle was covered with brachialis muscle. The skin was loosely reapproximated, and a large area of the fasciotomy in the posterolateral arm was left open. This was covered with bacitracin and Adaptic. He was placed in a supportive splint and awakened and transported to recovery in stable condition. At the end of the case, the hand was viable with a palpable radial pulse.

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PREOPERATIVE DIAGNOSES:
1.  Excessive abdominal skin and soft tissue after massive weight loss.
2.  Intertrigo and back pain secondary to large pannus.

POSTOPERATIVE DIAGNOSES:
1.  Excessive abdominal skin and soft tissue after massive weight loss.
2.  Intertrigo and back pain secondary to large pannus.

OPERATION PERFORMED:  Fleur-de-lis panniculectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

SPECIMENS:  None.

ESTIMATED BLOOD LOSS:  150 mL.

COMPLICATIONS:  None immediate.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old Hispanic female who underwent a laparoscopic gastric bypass approximately two years ago. She subsequently lost well over 100 pounds and has stabilized and plateaued at her current weight for the past three to six months. The patient came to the plastic surgery clinic complaining of intertrigo and back pain. She was approved for a panniculectomy. She was consented and explained the risks of the procedure, which include hematoma, seroma, wound breakdown. This was stressed that being on steroids she has a high probability of having wound complications. She has a history of DVT that has prompted us to preoperatively give her Fragmin as well as pneumatic compression boots. Her Fragmin will be continued postoperatively. The patient has signed consent saying that she understands the risks and benefits of the procedure.

DESCRIPTION OF OPERATION:  After explaining the potential risks and benefits of the procedure to the patient, informed consent was obtained. The patient was taken to the operating room by gurney and transferred to the operating room table in the supine position. An endotracheal tube was placed. General anesthesia was induced. One gram of Ancef was given preoperatively. The patient was then prepped with Betadine from table to table and from nipples to mid thigh with Betadine, draped in standard sterile fashion. A timeout was performed indicating patient, procedure, and site to be operated on.

The previously marked fleur-de-lis panniculectomy incision was followed on the table with a #10 blade. Electrocautery was used to dissect down to the level of the fascia. The skin and subcutaneous tissue was elevated up to the level of the umbilicus. The umbilicus was circumscribed and dissected down to its insertion into the abdominal wall fascia. We then continued the elevation of the skin and subcutaneous flap superiorly to a line above the umbilicus. We then had a vertical component that was incised in the midline from the xiphoid down to the umbilicus. We then dissected down with electrocautery to the level of the fascia. Her previous laparotomy incision was seen and the sutures were all in place. There were no hernias noted. We dissected out laterally from the midline along the vertical axis just down enough to mobilize tissue. Given the patient’s steroid use and history of smoking in the past, we decided to undermine as little as possible to maintain viability of the flaps and try to limit any complications. The patient is aware that she has a high probability of complications pertaining to this surgery.

After completing our dissections, we then achieved hemostasis with electrocautery. Three 19-French Blake channel drains were placed over the pubis and placed in the gutters in the midline. The incisions were all then closed in a layered fashion with 2-0 Vicryl sutures, deep 3-0 Vicryl sutures in the dermis, and a running 4-0 subcuticular suture. The umbilicus was pulled out and an area trimmed for it. It was placed then and secured with 5-0 nylon half-buried horizontal mattress sutures. Drains were placed on suction. All wounds were cleaned and benzoin and Steri-Strips applied as well as sterile gauze. Bacitracin and Adaptic were placed over the umbilicus. The patient tolerated the procedure well without any immediate complications. The patient was extubated, transferred back to a gurney, and taken back to the PACU. The patient left the operating room in good condition.

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