DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Connective tissue neoplasm, right parietal scalp.
POSTOPERATIVE DIAGNOSIS: Connective tissue neoplasm, right parietal scalp.
OPERATION PERFORMED: Excision of connective tissue neoplasm, right parietal scalp.
SURGEON: John Doe, MD
ANESTHESIA: MAC.
BLOOD LOSS: Nil.
COMPLICATIONS: None.
OPERATIVE FINDINGS: A 2 cm fluid-filled subdermal cyst extending down into the deep connective tissue but not involving the galea.
INDICATION FOR OPERATION: The patient is a (XX)-year-old, otherwise healthy Hispanic male who presented to the office with an enlarging mass over the right parietal scalp. The patient was having problems with discomfort on a regular basis and also interference with his ability to brush his hair. The lesion was quite obvious and he requested excision. The risks and benefits of the surgery were discussed with the patient, and the following procedure was performed.
DESCRIPTION OF OPERATION: The patient was positioned supine on the operating room table. He was given light intravenous sedation, and the area over the cyst was prepped and draped in the usual sterile fashion. Lidocaine 1% with epinephrine was used to create a regional block. A 15 blade scalpel was used to create an elliptical incision over the cystic lesion and dissection was taken lateral to the cyst down into the connective tissue, thereby excising the entire cyst down to the level of the deep connective tissue. The galea was not violated.
Small perforating arterial vessels were cauterized using a low wattage needle-tip cautery. Hemostasis was excellent. There was no spillage of the cystic contents into the wound. The specimen was sent in formalin solution to Pathology for evaluation.
The scalp tissues were closed in two layers using an undyed interrupted 4-0 Vicryl suture placed in an inverted fashion for the subdermal tissue. The skin was closed using surgical staples. Neosporin ointment was applied to the incision. Final needle and sponge count was correct. The patient was awake throughout and left the operating room in good condition. We will see him back in the office in one week.
