DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiple complex lacerations of face.
POSTOPERATIVE DIAGNOSIS: Multiple complex lacerations of face.
PROCEDURES PERFORMED:
1. Irrigation and debridement and complex repair of left cheek laceration.
2. Irrigation and debridement and complex repair of right cheek laceration.
3. Irrigation and debridement and complex repair of nasal laceration.
4. Irrigation and debridement and complex repair of right side nasal laceration.
SURGEON: John Doe, MD
ANESTHESIA: Local 1% lidocaine with epinephrine.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS: None.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Asian male who was assaulted with a bottle and sustained multiple complex facial lacerations. He presents for complex repair of these lacerations. The procedures were explained to the patient including the possible risks and complications, which include but are not limited to bleeding, infection, scarring, possible hypertrophic scar and keloid formation, possible wound breakdown with separation, contour irregularities, asymmetry of one side to the other, sensory changes around the skin area causing numbness, mental nerve injury causing mental nerve deficit, possible bruising, swelling, hematoma or seroma formation. The patient understands, agrees, and wishes to proceed with the repair.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in a sterile fashion. Lidocaine 1% with epinephrine was used for both anesthetic and hemostatic purposes. Once this was infiltrated to the wound edges and took effect, the wounds were copiously irrigated with saline solution. Hemostasis was then achieved with a cautery.
Some debridement was done with tenotomy scissors. A complex closure was done in multilayer fashion. The left cheek laceration was performed first, this was 4 cmm, followed by the right cheek laceration, which was 3 cm, followed by the nasal lacerations of 2 cm on the bridge and 1 cm on the right side.
They were closed in multilayer fashion utilizing 4-0 Vicryl suture in the subcutaneous tissue plane and the subdermal plane, in interrupted buried fashion. The skin was closed with combinations of running and interrupted 5-0 Prolene sutures. Dressing consisted of Neosporin. The patient tolerated the procedure well.
