DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Squamous cell cancer, right scalp.
POSTOPERATIVE DIAGNOSIS: Squamous cell cancer, right scalp.
PROCEDURES PERFORMED:
1. Excision of squamous cell cancer, right scalp.
2. Full-thickness skin graft to right scalp.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Twenty-six mL of 1% lidocaine with epinephrine and 0.25% Marcaine plain, 1:1 mix.
SPECIMENS: One lesion from right scalp, 5 x 5 cm.
COMPLICATIONS: None immediate.
BLOOD LOSS: Minimal.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who presents with a biopsy-proven squamous cell cancer of his right scalp. The patient is a transplant patient and has many comorbidities, so a large resection will be performed. The patient was consented for the procedure and understands the risks and benefits of the procedure, which include potential graft failure, scarring, and recurrence of cancer.
DESCRIPTION OF OPERATION: After explaining potential risks and benefits of the procedure to the patient, written consent was obtained, and the patient was taken to the operating room by gurney and transferred to the operating table in the supine position. Local anesthetic, listed above, was infused in the scalp and in the right supraclavicular area.
The dimensions to be excised were marked, 1.5 cm margins were made around the perimeter of the lesion, and a similar full-thickness skin graft was then taken from the supraclavicular area. Donor site was then closed primarily with 3-0 Vicryl sutures deep and a running 4-0 Monocryl superficially. Hemostasis was achieved with electrocautery prior to closure.
The full-thickness skin graft was then defatted and placed into the defect. The excised lesion was sent to pathology and marked in superior and anterior borders. Once the skin graft was placed, it was sewn into place with 4-0 chromic sutures deep and 5-0 nylon tie-over bolster was fashioned. The patient tolerated the procedure well without any immediate complications.
