DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Mammary hyperplasia.
2. Back and shoulder pain.
POSTOPERATIVE DIAGNOSES:
1. Mammary hyperplasia.
2. Back and shoulder pain.
OPERATION PERFORMED: Bilateral breast reduction.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old woman who has mammary hyperplasia out of proportion with the rest of her body. She has back, shoulder, and neck pain. Informed consent was obtained with the risks explained to include, but not limited to, bleeding, infection, pain, scarring, asymmetry, irregularities, loss of nipple, loss of nipple sensation, wound healing delays/problems, mammographic changes, fat necrosis, and the need for further operation.
DESCRIPTION OF OPERATION: IV antibiotics were given and general anesthesia administered. Both arms were abducted on arm boards and properly padded. A total of 40 mL of 0.5% lidocaine with epinephrine was injected into the medial, lateral, and superior aspects of the breast. Then, the chest was prepped and draped in the normal sterile fashion.
A standard inferior pedicle Wise pattern breast reduction was performed. The markings were made in the holding area, standing up, preoperatively. First, de-epithelialization was performed around the nipple-areolar complex on the right side. Then, a medial triangular wedge was excised almost down to, but not including, the pectoralis fascia. Then, a lateral wedge of skin, fat, and breast tissue was excised. Skin flaps were raised about 1.5 cm thick up to the clavicle. Once an adequate pocket was obtained, then a keyhole was excised superiorly for laser insetting of the nipple. The inferior pedicle was trimmed. The wound was hemostased with electrocautery and temporarily stapled shut.
The same procedure was performed on the left. First, de-epithelialization around the nipple, then triangular excisions were made medially and laterally. Skin flaps were raised. The keyhole was excised. The inferior pedicle was trimmed. The left side was palpated and compared to the right, and it seemed similar. Then, cautery was used for hemostasis and then the left breast was temporarily stapled shut.
The patient was made to sit up and the sides were compared. The left appeared a little bit bigger, so the left was opened and a little bit more tissue was removed. Final weights were 495 grams on the right and 545 grams on the left. The breasts were marked right and left breast tissue and sent for pathology.
Then, each breast was irrigated with saline solution and checked for hemostasis. The nipple remained pink and viable on both sides. The breasts were closed in layered fashion. The horizontal and vertical limbs were closed with buried interrupted 3-0 Vicryl and running 4-0 Monocryl subcuticular stitch. The nipple-areolar complexes were inset with 3-0 Vicryl and 4-0 Monocryl and then some 5-0 nylon. The wounds were dressed with bacitracin, Adaptic, sterile gauze and a surgical bra.
There were no apparent complications. The patient tolerated the procedure, was extubated, and taken to PACU in satisfactory condition. At the end of the case, all counts were correct.
