DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Bilateral breast asymmetry and ptosis, status post left lumpectomy and radiation therapy for cancer.
POSTOPERATIVE DIAGNOSIS: Bilateral breast asymmetry and ptosis, status post left lumpectomy and radiation therapy for cancer.
OPERATION PERFORMED: Bilateral mastopexy for symmetry, status post cancer surgery.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia with LMA.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 100 mL.
DRAINS AND TUBES:
1. Foley catheter.
2. Jackson-Pratt drain x2.
SPECIMENS:
1. Left breast tissue to pathology.
2. Right breast tissue to pathology.
DESCRIPTION OF OPERATION: In the preoperative holding area with the patient in a sitting position, we did measure and mark the planned procedure using a Wise pattern and 20 cm from midclavicular line, which was at 8 cm from suprasternal notch and similarly 20 cm from the suprasternal notch was taken on both sides. The nipple on the left side was 1 cm higher than that on the right, but the inferior pole of the breast was considerably lower.
The patient was taken to the operating room and placed in the supine position on the operating room table. All appropriate monitoring equipment was attached. At this point, general anesthesia was uneventfully instituted, including with LMA placement. Ancef 1 gram was given as prophylaxis. Pneumatic compression boots were put in place and used throughout the entire procedure. Foley catheter was inserted. The operative site were carefully examined and then scored with an 18 gauge needle taking the 10 cm central pedicle of 10 cm vertical height. The entire operative site was prepped with Betadine in the usual manner. Sterile drapes were applied in the usual fashion. With excellent illumination and loupe magnification, the procedure was undertaken.
On the left side, because of the nature of the radiation, we did de-epithelize the entire central pedicle, including the excess tissues in the triangles and where the new nipple location would be. This was all done with a #15 blade. The removed tissue was sent for pathology. The periphery was now dissected with the Bovie cautery device, starting at just about 1 cm thickness and then coming thicker toward the base to try to maintain the best possible blood supply, leaving the entire central pedicle of the radiated breast intact. Meticulous hemostasis was obtained. No abnormalities were seen or palpated beyond the fibrous nature of the thickened breast, and no additional tissue was removed. The left breast was irrigated with saline plus bacitracin and a 10 mm Jackson-Pratt drain was placed through separate inferolateral stab wound. This was sutured to the skin with 3-0 Vicryl. The central pedicle now realigned with buried 3-0 Vicryl sutures. An additional buried 3-0 Vicryl was used to close the deep tissue. All of these deep stitches were placed below the dermis. We tried to avoid any sutures within the dermal plexus to minimize compromise of the tissues.
The skin was then closed with a running half-locked trailing vertical mattress suture of 4-0 Novafil for the inframammary portion, in the same pattern but with 5-0 Novafil for the vertical segment, and 5-0 Novafil in simple running fashion was placed around the nipple-areolar complex. The nipple was raised to the desired point, and the breast was better shaped without the extreme flattening and tissue loss in the lower pole. However, the tissue was very taut and was going to have a difficult time being reshaped just because of the radiation effects. However, the blood supply seemed to be intact and the tissue showed good vitality with excellent capillary refill to the nipple-areolar complex. The drain was initially placed to wall suction and then to self-contained suction.
Gloves were changed. Then attention was directed to the right side. The central pedicle was de-epithelialized primarily with the avulsion technique, and the excess tissue to the medial and lateral wedges and also superiorly where the new nipple-areolar sites were wedge excised into the deeper tissue. This was all sent for pathology. Meticulous hemostasis was obtained as it had been on the left side using topical 1:100,000 epinephrine and also Bovie cautery. The superior breast flap was then elevated, starting at about 1 cm thickness and going thicker toward the base, as had been done on the left side. The central pedicle was additionally manipulated and after several trials to see size, match, and shape, additional trimming was done with all of this tissue being sent for pathology. The right breast area was irrigated with saline plus bacitracin, and it was closed in similar fashion to the left.
Both sides were now cleansed and dressing was applied using Adaptic, Polysporin ointment, ABDs, and bra. Needle and sponge counts were correct at the end of the case. The procedure being ended, anesthesia was also ended, and the patient was escorted to the recovery area having tolerated the procedure and anesthesia satisfactorily.
