DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Nasal deformity.
2. Chin recession.
POSTOPERATIVE DIAGNOSES:
1. Nasal deformity.
2. Chin recession.
OPERATION PERFORMED:
1. Rhinoplasty.
2. Chin augmentation.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was admitted to the preoperative holding area. While in the supine and semi-sitting positions, the stair-step columellar incision as well as pertinent nasal anatomy, including dorsal hump, widened nasal base, widened alar base, and excessive alar cartilages were marked with a surgical pen. The patient received 1 gram of Ancef preoperatively. Bilateral SCDs were placed. The patient was then brought back to the operating suite and placed supine on the operating table. Both SCDs were made functional, at which time general anesthesia was then induced. An endotracheal tube was secured with a 2-0 silk suture. This will be removed at the completion of the procedure. A throat pack was also placed as was a Foley catheter. Tetracaine eye drops, Lacri-Lube ointment, and bilateral corneal protectors were placed. A total of 12 mL of 1% lidocaine with epinephrine was infiltrated in the soft tissue of the nasal area, including bilateral infraorbital nerve blocks. The patient’s face was prepped with Betadine and surgically draped. Oxymetazoline packs were then placed into the internal nasal vestibule bilaterally.
After adequate time had transpired, the previously marked stair-step transcolumellar incision was opened with a #11 blade scalpel. The mid portion of the lower alar cartilages at the columella was then identified and a supraperichondrial plane dissected over the chip area, including the width of cephalically rotated lower lateral cartilages. Next, the dorsal caudal septum was exposed and the dissection proceeded up to the nasal bones, which were found to have a convex shape as well. The subperiosteal elevation of the nasal bone area centrally was then performed. After initial antibiotic irrigation and hemostasis, the osseous portion of the dorsal hump was rasped with Snowden-Pencer #5 and #6 rasps. Next, the dorsal septum was trimmed with Micrins super sharp septal scissors commensurate with the height of the nasal bones. After checking the profile under direct vision as well as with the skin redraped, the lower lateral cartilages were then marked and alar strip resection, leaving 5 mm of alar cartilage inferiorly along the entire length of the cartilage, was then performed. With the cartilages in repose, the domes matched symmetrically.
Next, a partial transfixion incision was made along the caudal septum, at which time conservative resection of the caudal septum was made. Next, a partial bilateral inferior turbinectomy was performed with scissors followed by cauterization. No excessive bleeding was seen during the entire procedure. The nasal cavity was then irrigated with Betadine followed by antibiotic solution. Next, the intranasal incisions were closed with interrupted 4-0 chromic suture. A single 6-0 buried clear Vicryl suture was placed at the mid portion of the dermis of the transcolumellar incision. The remaining columellar incision was closed with interrupted 6-0 nylon sutures. Next, 3 mm Weir excisions were made at the alar base. After these triangulated skin wedges were removed, hemostasis was achieved followed by antibiotic irrigation and single dermal suture closure at each incision. Final skin closure of these areas was performed with running 6-0 nylon sutures. It should be noted that bilateral low-to-high osteotomies through a combination of intranasal as well as percutaneous approach were performed bilaterally prior to the Weir excisions. Next, a soft splint followed by an aluminum Denver splint were placed in addition to bilateral Merocel nasal packings with an internal airway that was soaked with bacitracin ointment. Both packs were secured with an external 2-0 silk suture to prevent any postoperative aspiration.
Finally, attention was directed to performing the chin augmentation. With the chin implants soaked in antibiotic solution, bilateral mental nerve block as well as infiltration of the precise pocket, measured prior to surgery, was performed using 1% lidocaine with epinephrine. After adequate time had transpired, a 2.5 cm intraoral incision was made 6 mm inferior to the intraoral mandibular vestibule. The dissection proceeded subperiosteally, centrally, avoiding exposure or injury to the bilateral mental nerves. The inferior pocket along the jaw line was then developed with Freer elevators. After initial Betadine followed by antibiotic irrigation, the extended median anatomic Implantech chin implant was placed into the pocket in a precise location.
Next, additional antibiotic irrigation was performed and incision closed with three interrupted 4-0 Vicryl sutures. The patient tolerated the procedure well. Estimated blood loss was less than 20 mL. All sponge and needle counts were correct. There were no complications. Foley catheter was removed prior to extubation as was a lower Bair Hugger used to prevent intraoperative hypothermia as was the throat pack. In addition, bilateral corneal protectors were removed, and irrigation with balanced salt solution was performed. The patient was extubated in the operating room and transferred to the recovery room in stable condition.
