DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Mohs micrographic surgery induced basal cell carcinoma related defect of left upper eyelid margin.
POSTOPERATIVE DIAGNOSIS: Mohs micrographic surgery induced basal cell carcinoma related defect of left upper eyelid margin.
OPERATION PERFORMED: Reconstruction of left upper eyelid margin utilizing marginal apposition with local myocutaneous flap formation.
SURGEON: John Doe, MD
ANESTHESIA: Topical ocular, total intravenous, local infiltrative with monitored anesthesia care.
ANESTHESIOLOGIST: Jane Doe, MD
SPONGE AND INSTRUMENT COUNT: Correct.
ESTIMATED BLOOD LOSS: 15 mL.
INDICATIONS FOR OPERATION: This (XX)-year-old gentleman was noted to have a defect of the left upper eyelid margin after undergoing Mohs micrographic resection of residual basal cell carcinoma. The defect involved three-quarters of the lid thickness, including all of the anterior lamella.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating room table. Previously, a gentian violet marking pen had been used to mark the fullest clinical extent of the defect after the tight pressure patch was removed and the eyelid skin defatted with an alcohol pad. Also, the lateral palpebral raphe was marked with the same pen should additional laxity be required. The patient received appropriate preoperative sedation and monitoring and instillation of 2% lidocaine with 1:100,000 parts epinephrine, a 25% mixture of 0.75% bupivacaine was instilled subcutaneously along the length and breadth of the left upper eyelid. Additionally, the left lateral canthus was also infiltrated with this same solution. The anesthetic agent was massaged into place. The surgeon performed a surgical scrub.
Upon his return, the patient was prepped and draped in the usual sterile fashion for ophthalmic surgery. A hard corneoscleral shield was placed before the cornea on the left side after a series of 0.5% tetracaine drops had been applied. The defect was then examined, and additional full-thickness resection was required to allow for wound apposition. This converted the defect into one in which an H flap could be fashioned for closure of the myocutaneous section. The sharp Westcott scissor was then used to resect the tissue. The area of the lateral and medial section was globalized to allow for flap formation and apposition. A series of preplaced sutures were then used to anastomose at the area just anterior to the mucocutaneous junction. The eyelash line and the remnant of lateral and medial tarsal plate were then anastomosed with preplaced sutures as well. The lid margin was then anastomosed first at the area just anterior to the mucocutaneous junction. The eyelash line and then the gray line were anastomosed with a 6-0 Vicryl suture as well. The deep 5-0 Vicryl sutures were then anastomosed as these had been preplaced. We developed myocutaneous tissue laterally, which was then anastomosed with a series of deep buried 6-0 Vicryl sutures. The eyelid level and contour was noted to be appropriately reformed. A horizontal relaxing incision was then repaired with a series of deep buried 6-0 Vicryl sutures.
The cutaneous layer was then closed with a series of interrupted and continuous locking 6-0 fast-absorbing plain suture. The eyelid level and contour remained appropriate. The hard corneoscleral shield was removed and then replaced with a ProShield soaked in balanced salt solution. The wounds were dressed with TobraDex ointment. A cool moistened eye pad was placed. An ice pack was placed. The patient tolerated the procedure well and was turned over to Anesthesia and then removed to the recovery room in stable condition.
