DATE OF OPERATION: MM/DD/YYYY
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.
