Plastic Surgery Medical Transcription Operative Sample Report


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Excessive abdominal panniculus and lipodystrophy, bilateral flanks and breasts.

POSTOPERATIVE DIAGNOSIS:  Excessive abdominal panniculus and lipodystrophy, bilateral flanks and breasts.

OPERATION PERFORMED:  Abdominoplasty with muscle plication and liposuction, bilateral flanks and bilateral breasts.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, ARNP

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Jill Doe, CRNA

DESCRIPTION OF OPERATION:  The patient was marked preoperatively in the holding area outlining the excessive abdominal panniculus as well as the localized lipodystrophy areas.  He was then brought to the operating room, placed supine over the operating table.  Under general anesthesia, his entire torso from the clavicles down to his upper thighs including his pelvis was prepped circumferentially with Betadine soap and solution and draped sterilely.  Tumescent solution was infiltrated into the areas for liposuction using total for all areas of approximately 2500 mL.  The flanks were aspirated next, removing from these two areas approximately 1300 mL.  The abdominoplasty was then carried out by circumscribing the umbilicus and leaving it attached to the stalk.  The skin incisions were made and carried down to the abdominal wall musculature removing the excess abdominal panniculus, which weighed approximately 1300 grams.  The rectus diastasis was moderate and therefore this was closed with interrupted #0 Ethibond figure-of-eight sutures completely snugging up the midline. 

All wounds were irrigated with Kantrex solution after which two 10 mm Jackson-Pratt drains were placed in the wound and brought out through separate stab wounds in the inguinal crease.  These were secured with #3-0 black silk sutures.  The table was flexed slightly after which the lower abdominal incision was closed in layers with #2 and #3-0 Vicryl. The fascial layers were closed with interrupted #2-0 Vicryl in the subcutaneous and subcuticular closed with #3-0 Vicryl.  Stainless steel clips were then used to align the skin edges.  The umbilicus was brought through a stab wound in the abdominal wall and secured in placed with #3-0 Vicryl and #4-0 Vicryl Rapide sutures.
 
Sterile dressings were applied along with an abdominal binder as well as a compression vest.  The patient was then transferred from the operating table to the recovery room having tolerated the procedure without difficulty.  Total aspirant from the liposuction was approximately 1800 mL, of which approximately 150 to 200 mL was thought to be red blood cells.  The patient was transferred from the operating table to the recovery room having tolerated the procedure without difficulty.


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OPERATIONS PERFORMED:
1.  Laser resurfacing, perioral and periorbital skin.
2.  Bilateral lower blepharoplasty with temporary tarsorrhaphy.
3.  Excision of medial fat pad of upper eyelids.
4.  Bilateral subcutaneous brow lift.
5.  Facelift with submental liposuction.
6.  Extra small chin augmentation.

DESCRIPTION OF OPERATION:  With the patient on the operating table in the supine position, after administration of anesthesia, a Foley catheter was placed by the nurse and hooked to straight drainage. SCD hose was utilized as well as a Bair Hugger. The eyelid skin was cleansed and the endotracheal tube protected with aluminium foil. Laser eye shields were placed in the eyes. Utilizing the TruPulse carbon dioxide laser, the lower eyelid and upper eyelid skin were resurfaced with two passes at 300 millijoules, pulse 10. The skin was cleansed between each pass, as with all lasering, and dried. The glabellar skin was resurfaced with two passes at 400 millijoules as well as the periorbital skin and the vermilion-cutaneous junction. The eye shields were removed. The patient was prepped with Betadine and draped. Facelift incisions were marked in gentian violet utilizing a tragal flap. A submental incision was marked for the chin augmentation. The lateral brow lift incisions were made beginning at the mid pupil line at the anterior hairline extending for 2-1/4 inches curvilinear into the lateral hairline bilaterally. Infiltration anesthesia was performed utilizing 1% lidocaine with epinephrine into the lower eyelids and the medial fat pad of the upper eyelids and the lateral forehead and brow.

Surgery was begun on the right lower eyelid. An incision was made and a muscle flap developed; however, muscle was left over the mid lamella. The bleeders were coagulated. The septum orbitale was opened and the 3 compartments of fat, medial, middle, and lateral, were identified. The herniating portions were dissected free, crossclamped at their base, resected and coagulated. Due to the deep tear trough, a dissection was carried out over the orbital rim medially, and a small piece of fat that had been removed from the lower lid was trimmed and placed in this dissected area to fill out the tear trough. The lid was then laid back to its anatomical position. Approximately 1 to 1.5 mm of skin was resected since the laser had tightened the lower lid skin. The incision was closed with a running 6-0 fast-absorbing catgut suture.

The right upper eyelid medial fat compartment was then opened in the pretarsal crease. The herniating fat was dissected free, crossclamped at its base, resected and coagulated. Bleeders were coagulated, and the incision closed with a running 6-0 fast-absorbing catgut suture. A temporary tarsorrhaphy suture was placed at the lateral eyelids with 6-0 fast-absorbing catgut suture. The right temporal incision was made and dissection carried out in a subcutaneous plane, taking care to leave the superficial sensory nerves intact. This was carried down to 1 cm above the supraorbital rim. Bleeders were coagulated. The flap was then elevated and rotated slightly medially, elevating the lateral brow to the proper position. A key incision was made through the flap and a 4-0 nylon suture placed. The excess skin was then trimmed on each side. A running 4-0 nylon suture was utilized for the closure. The exact same procedure was carried out on the left lower and upper eyelids as well as the lateral brow, with the same techniques.

The left side of the face was infiltrated with 50 mL of 0.5% lidocaine with epinephrine diluted with 100 mL of saline. After the incisions were made, subcutaneous dissection was carried out, leaving a moderately thick flap in the postauricular skin. Dissection was carried down onto the neck and out over the cheek below the zygomatic arch. Bleeders were coagulated. The spatula cannula was then utilized for vacuum technique liposuction of the submental fat pad through the lateral flap. A small piece of fibrillar was placed in the submental area while the remaining portions of the procedure were completed. The lateral platysma was then grasped with a pickup and undermined with a scalpel. This was undermined at the angle of the mandible for approximately 1.5 cm. This tapered down to 0 cm along the lateral border. A curvilinear arc of SMAS was then resected with Joseph scissors from near the base of the lobule, which connected to the incised platysma up to just under the zygomatic arch. This was closed with a running 3-0 white Surgilon suture which plicated the SMAS. The lateral edge of the platysma muscle was then pulled in a superior-lateral direction and anchored to the mastoid fascia with 3-0 Vicryl suture. The lateral border of the platysma was then sutured along the sternocleidomastoid fascia with a running 3-0 Vicryl suture. This was reinforced with a running 3-0 white Surgilon suture. After a final check for hemostasis, a #10 round JP drain was placed in the neck, brought out through a stab incision, and sutured in place with 3-0 Vicryl suture.

A solution of 5.5 mL of 1% lidocaine with epinephrine was mixed with 0.5 mL of Depo-Medrol. This was shaken in the syringe and 3 mL was sprayed over the soft tissues for postoperative analgesia. Marcaine 0.25% with epinephrine 10 mL was infiltrated into the incision lines and the postauricular cartilage for postoperative analgesia. The skin flaps were then advanced and trimmed. The ear lobule was suspended free-floating by anchoring the posterior skin to the postauricular sulcus with 2 interrupted 5-0 Monocryl sutures. One was placed at the inferior and superior pole of the tragus. Preauricular closure was with a running 4-0 nylon suture. The hair-bearing and postauricular sulcus incisions were closed with a running 3-0 plain catgut suture. The same procedure was carried out on the right side of the face with the exact same technique.

The chin had been infiltrated with 1% lidocaine with epinephrine, a total of 8 mL. The incision in the submental crease was opened. It was dissected up over the mental process, and a pocket dissected with a periosteal elevator and scissors. This was made to the dimensions of the extra small chin implant. The chin implant was soaked in Betadine, inserted, and positioned. A single 5-0 Monocryl suture was placed in the deep tissues and the skin closed with a running 4-0 Prolene suture.  A Steri-Strip was placed over it. The patient's hair was washed. It should be noted that 1 drop of Pred Forte ophthalmic solution was placed in each eye at the completion of the eyelid surgery, and Lacri-Lube. Aquaphor ointment was then applied to the laser treated areas. The patient tolerated the procedure well and was sent to recovery room in good postoperative condition. Estimated blood loss was 40 mL.

 
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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Lipodystrophy of abdomen, hip and flank areas.
 
POSTOPERATIVE DIAGNOSIS:  Lipodystrophy of abdomen, hip and flank areas.
 
OPERATION PERFORMED:  Liposuction of the upper and lower abdomen and hip and flank areas.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  General endotracheal.
 
ANESTHESIOLOGIST:  Jane Doe, CRNA
 
INDICATIONS:  This is a (XX)-year-old female who requested liposuction of her abdomen, hips and flank areas.  After a long consultation with the patient, we had discussed tummy tuck procedures versus liposuction.  However, because of the recovery time involved in tummy tuck procedures, she requested liposuction at this time understanding that loose skin may occur and require a later abdominoplasty with skin excision.  This was okay with the patient and understood that we may plan on a secondary stage where tummy tuck is performed with excision of the skin.
 
FINDINGS:  Liposuction, total in was 3 liters and total out was 3200 mL.
 
DESCRIPTION OF OPERATION:  After obtaining a written consent, which included but was not limited to infection, bleeding, hematoma, seroma, asymmetries, contour irregularity, divots in the skin, scars, DVT, pulmonary embolus and need for further surgical revision, the patient understood and agreed to proceed.  She was marked in the preoperative holding area.  She was then brought to the operating room table, placed in a supine position and placed under general endotracheal anesthesia.  Sequential compression devices were placed in the lower extremities.  The future stab incisions for the liposuction cannulas were infiltrated with 1% Xylocaine and 1:100,000 solution of epinephrine.  Total of 10 mL was used.  She was then prepped and draped in the usual fashion.
 
Following this, infiltration of the skin and subcutaneous tissue was performed using the tumescent fluid, which contained per liter, 10 mL of lidocaine and 1 amp of epinephrine.  This was then tumesced into the subcutaneous tissues being careful not to injure any nerve lines around organs or viscera.  A total of 3 liters was infiltrated into the abdomen, abdominal subcutaneous tissue and hip and flank areas.  After this was allowed to take effect, liposuction was then performed through appropriately placed 3-mm stab incisions.  Liposuction was then performed with 600 mL removed from the lower abdomen, 400 mL from the upper abdomen and approximately 600 mL from each flank area.  Suctioning was performed using serial cannulas starting with 3.5 mm and 3.0 mm cannulas and feathering and tapering was performed using smaller cannulas.  Good contour was noted and suctioning was stopped.  Symmetry was noted.  There were no significant irregularities in skin or contour deformities noted.  All the incision points were closed with interrupted #5-0 nylon sutures.  Dressings were applied.  She was extubated and brought to the recovery room in stable and satisfactory condition.
 


DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Lipodystrophy of the abdomen.
 
POSTOPERATIVE DIAGNOSIS:  Lipodystrophy of the abdomen.
 
OPERATION PERFORMED:  Suction-assisted lipectomy of the abdomen.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Jane Doe, CST
 
ANESTHESIA:  General.
 
ANESTHESIOLOGIST:  Jill Doe, CRNA
 
BLOOD LOSS:  Minimal.
 
COMPLICATIONS:  None.
 
SPECIMENS:  None.
 
INDICATIONS:  The patient is a (XX)-year-old white male who is relatively thin but has mild to moderate fatty prominence of the central abdomen as well as the lateral abdomen focally.  He presents for suction-assisted lipectomy of these sites.
 
DESCRIPTION OF PROCEDURE:  The patient was seen in the preoperative area where, in the standing position, the abdominal skin was wiped with alcohol and marked with a marking pen for surgery.  The patient was brought into the operative room and placed supine on the operating room table and administered general anesthesia successfully.  A total of 5 mL of 50:50 mixture of 1% lidocaine with epinephrine with 0.25% Marcaine with epinephrine was infiltrated into the site of liposuction, access site incisions.
 
The abdomen was prepped and draped in the usual sterile fashion.  Stab incision was performed with #15 blade, which was dilated with a hemostat in the high lateral flank superior margin of the umbilicus and in the groin on each side.  Tumescent solution, which is the standard mixture of 20 mL of lidocaine, 1 mL adrenaline and a liter of warm normal saline was injected throughout the subcutaneous plane.  Suctioning was then performed after a wait of 10 minutes plus with the 3 mm triport cannula throughout the anterior and lateral abdomen with shorter cannulas being used for the upper abdomen.  All sides were remarkably thinner.  Good smooth contour.  Total infiltration amount was 1100 mL.  Total output 950 mL, which appeared to be about 50% to 60% fat by volume.
 
Incisions were closed with #5-0 Prolene interrupted sutures x2.  Incisions were clean, dried and dressed with broad Band-Aid dressings, gauze pads and abdominal binder.  The patient tolerated the procedures well with no apparent complications.  The patient was then extubated in the operating room and transferred to the recovery room in a satisfactory condition.  Postoperatively, following the procedure, I spoke to the patient in regards to procedure and postoperative care.


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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSES: 
1.  Aging, post weight loss, loss of chest wall contour and fullness.
2.  Persistent periumbilical iliac crest adipose tissue, status post previous lipoplasty x2.
3.  Left nipple scar.
 
POSTOPERATIVE DIAGNOSES:
1.  Aging, post weight loss, loss of chest wall contour and fullness.
2.  Persistent periumbilical iliac crest adipose tissue, status post previous lipoplasty x2.
3.  Left nipple scar.
 
OPERATIONS PERFORMED: 
1.  Placement of bilateral subpectoral muscle male breast implants for augmentation. Right subpectoral implant, Allied Biomedical Novak Pec implant. Left subpectoral implant, Allied Biomedical Novak Pec implant. Size one for both left and right subpectoral implants.
2.  Revision abdominal wall lipoplasty.
3.  Scar revision, left nipple.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None. 
 
ANESTHESIA:  General.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
NURSE ANESTHETIST:  Barbara Doe, CRNA
 
ESTIMATED BLOOD LOSS:  30 mL.
 
BLOOD PRODUCTS:  None.
 
REPLACEMENT:  Intravenous crystalloid.
 
DRAINS:  None.
 
SPECIMENS:  None.
 
COMPLICATIONS:  None.
 
NEEDLE AND SPONGE COUNTS:  Correct x2 at the completion of the procedure.
 
DESCRIPTION OF OPERATION AND FINDINGS:  In the presurgical holding area, markings were undertaken for the pocket position of the submuscular chest wall implant as well as the location for surgical incisions. In addition, markings were undertaken of the abdominal wall for utilizing the old incisions for lipoplasty of the abdominal wall and for the areas to undergo revision lipoplasty. In addition, areas overlying the left nipple requiring scar of revision. Next, the preoperative nurse placed bilateral TED hose and SCD hose. Next, a peripheral intravenous line was initiated by the preoperative room nurse and prophylactic and intravenous antibiotics were administered. Next, the patient was transported to the operating room where, upon arrival, his SCD hose was connected to the SCD pump, padding was placed to the bilateral heels, a pillow underneath the knees and a gel pad for the head.
 
After induction of general anesthesia, the upper extremities, chest wall and abdominal wall were prepped and draped in usual sterile manner. Attention was first directed towards the subpectoral-submuscular implant placement. Lidocaine 1% with epinephrine 1:100,000 concentration with equal 0.25% Marcaine 1:200,000 concentration was used to infiltrate the borders of the subpectoral implant pocket as well as surgical incisions. Approximately, 60 mL of solution was utilized. Next, through a separate 4 mm incision, a vasoconstricting solution consisting of lactated Ringer's 500 mL to which was added 2 mL of lidocaine concentration 1:1000 was used for infiltration of the subpectoral pocket. Approximately, 50 mL of this solution was placed in the right subpectoral pocket and 50 mL in the left subpectoral pocket through a similarly placed incision.
 
Next, the surgeon's double gloves were changed. The Allied Medical implants, which had been previously sterilized, were then removed from the sterile packing and placed in a solution of Betadine diluted 50% with normal saline. Next, through the right axillary incision, access to the subpectoral pocket was created. After access to the subpectoral pocket was created utilizing the border superiorly of the second rib, medially within 1 cm of the sternum, inferiorly the inframammary fold, and laterally the lateral extend of the implant size. This pocket was created utilizing a Richardson elevator. Following the completion of the pocket, the pocket was then irrigated utilizing a rubber catheter with approximately 300 mL of antibiotic-containing normal saline solution until the fluid was clear. Next, Betadine normal saline-soaked lap pad was then placed into the incision and into the pocket. A similar pocket was then created for the left subpectoral implant and similarly irrigated with antibiotic normal saline solution until clear and similarly packed with Betadine normal saline-soaked lap pad. Next, the surgeon's double gloves were changed as they had been when previously handling the implant.
Next, the right breast implant was trimmed superiorly, laterally, inferiorly and medially to match the contour of the right breast and chest wall. In a similar fashion, the left breast implant was also shaped and in addition approximately 30% of projection of the implant was reduced with sculpting due to the prominence of the left chest wall and breast compared to the right chest wall and breast. Next, the implants were again irrigated with antibiotic normal saline solution and then again soaked in Betadine normal saline solution.
 
Next, the right chest wall lap pad was removed and again irrigated with antibiotic normal saline and then irrigated with Betadine normal saline solution. Using Dr. Mladick's no-touch technique, the right breast implant was placed in the subpectoral pocket. The pocket was then positioned. Next, the left axillary and left subpectoral pocket lap pad was removed. The pocket was again irrigated with antibiotic normal saline solution. The axillary incision and pocket were irrigated with Betadine normal saline solution. Next, utilizing Dr. Mladick's no-touch technique, the left breast implant was placed in the subpectoral pocket and was positioned. It should also be noted that the surgeon's double gloves were changed prior to handling the left subpectoral implant.
 
The patient was then placed in a sitting position on the operating table. The implants’ position was then adjusted and improvement in symmetry was achieved. Next, the surgical incisions were again irrigated with antibiotic normal saline solution followed by Betadine normal saline solution. Three interrupted sutures of 0 Prolene were then used to suture the most superior lateral portion of the implant to the chest wall musculature. This was achieved bilaterally. Next, the incisions were closed in three layers, a deep layer of 2-0 undyed Monocryl, followed by 3-0 undyed Monocryl, followed by subcuticular 3-0 undyed Monocryl, and followed by Dermabond solution.
 
Next, attention was directed towards the left nipple scar. Lidocaine 1% with epinephrine 1:100,000 concentration was used to infiltrate the site. Thereafter, the scar from approximately the 7 o'clock position to the 11 o'clock position was revised as well as from the 1 o'clock position to 5 o'clock position. After removal of the scar, the incision was closed in two layers, a deep layer of 4-0 undyed Monocryl followed by 5-0 fast absorbing plain gut.
Attention was then directed towards the abdominal wall. Through the old lipoplasty abdominal wall incisions, lidocaine 1% with 1:100,000 concentration was used for infiltration. After adequate vasoconstriction, the 3 incisions were then reopened with a scalpel and superwet solution, approximately 1 liter, was placed in the anterior abdominal wall and iliac crest regions. Next, utilizing 3 mm and 4 mm blunt tip, round, 3-holed lipoplasty cannulas as well as a 4 mm, flat 2-hole lipoplasty cannula, lipoplasty of the anterior abdominal wall focused on the periumbilical regions as well as the iliac crest regions was undertaken. Approximately, 400 mL of supernatant fat was removed.

 
Next, the incisions were closed with 5-0 Vicryl undyed for the deep dermis and 5-0 Prolene. It should also be noted that 5-0 undyed Vicryl and 5-0 Prolene were used for closure of the incisions used on the chest wall for placement of the vasoconstricting solution. Xeroform gauze as well as Medipore dressings were applied to the various incision sites. In addition, for the chest wall, a Kerlix roll was placed on the axilla, followed by an Ace wrap for the chest wall, followed by chest wall compression garment. For the abdominal wall, following placement of the Medipore dressings, an abdominal wall binder was placed. The patient tolerated the procedure well. He was extubated in the operating room and taken to recovery room in stable condition. He was then placed on 23-hour observation status.
 





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