DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Aging face.
POSTOPERATIVE DIAGNOSIS: Aging face.
OPERATIONS PERFORMED: Rhytidectomy, endoscopic brow lift, upper lid blepharoplasty, lower lid blepharoplasty and periorbital fat transfer.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Negligible.
FLUIDS: Crystalloids.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. SCDs were in place and functioning prior to the induction of general endotracheal anesthesia. A Foley catheter was inserted. Lacri-Lube was placed in the eyes and the patient’s head and neck prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was injected into the scalp incisions that were used for an endoscopic brow lift. The lateral vectors of the pole had an incision placed at the apex in the scalp. Two paramedian incisions were placed in the scalp on either side of the midline. A 15 blade was used to make the incision followed by dissection of the subperiosteal plane. Dissection was performed to the orbital rim where the periosteum was incised lateral to the supraorbital neurovascular bundle bilaterally. Medially, the patient’s periosteum was incised with the corrugator muscle group partially excised. Z retractor was placed with the forehead advanced in the superolateral direction with the 2 x 8 mm endoscopic screw placed through the outer cortex and a 2-0 PDS placed through the composite flap to the microscrew. This was performed bilaterally. The incisions were then closed with a stapling device.
Attention was then turned next to the face. An incision was made along the temporal hairline, along the sideburn, along the root of the helix in the post-tragal area, along the lobule, along the postauricular sulcus. The skin was elevated with the help of transillumination, blepharoplasty scissors. After the skin was elevated in a limited fashion, an SMAS flap was then designed along the body and arch of the zygoma and then inferiorly beyond the angle of the mandible. The SMAS flap was elevated from lateral to medial and from superior to inferior with the dissection performed to the zygomaticus major muscle across the masseteric cutaneous ligaments and inferior to the angle of the mandible. The SMAS was doubled over at the lateralmost section and advanced in a superolateral direction and affixed the superficial layer of the deep temporal fascia with 3-0 Surgilon. The platysma was advanced to the mastoid using a 3-0 Surgilon. Further inset was performed along the arch, body of the zygoma and on the neck. Irrigation was performed followed by meticulous hemostasis. The above was then repeated on the opposite side of the face.
Suction-assisted lipectomy was performed in the submental region with a submental incision then performed and dissection performed to the cricoid cartilage. The medial borders of the SMAS were advanced to the midline with a plication performed with a buried 3-0 Surgilon. A back cut was performed at the cricoid cartilage. The flaps were then evaluated with the skin advanced in the superolateral direction and a pilot cut performed with a 3-0 Surgilon placed at the apex of the helix. A 7-French JP drain was placed in the subcutaneous plane followed by another cardinal stitch placed in the postauricular sulcus with 3-0 nylon. The redundant skin was excised. The preauricular skin was closed with a running 6-0 Prolene followed by the postauricular skin closed with an interrupted 5-0 Prolene followed by defatting of the tragal flap and inset over a de-epithelialized tragus with fast-absorbing gut. The postauricular sulcus was closed with 5-0 Prolene. The above was then repeated on the opposite side of the face. The submental region was then closed with running 6-0 Prolene.
Attention was then turned to the eyes. A very conservative upper lid skin excision was performed with greater skin excised from the right than the left. Injection was performed with 1% lidocaine with 1:100,000 epinephrine. The pattern of skin excision had previously been planned with the patient awake and alert in the holding area with the amount of skin estimated. A 15 blade was used to make a skin-only excision. The orbicularis and septum were perforated nasally with a modest amount of the central fat pad excised. The upper lid was then closed with a running 5-0 Prolene. The above was then repeated on the opposite eye.
Corneal protectors and Lacri-Lube were placed. Lidocaine 1% with 1:100,000 epinephrine was injected along the potential subciliary incision. A 15 blade was used to make the incision followed by enlarging the incision using blepharoplasty scissors. The skin-only dissection was performed to the junction of the pretarsal and preseptal orbicularis where a submuscular plane of dissection was then obtained. The arcus marginalis was incised using electrocautery along the inferior orbital rim. A modest amount of fat was excised from the medial, central and lateral fat pads using electrocautery. A preseptal orbicularis flap was created, which was then affixed to the lateral orbital rim using a 4-0 Monocryl. The redundant skin was excised. Closure was performed with a 6-0 fast-absorbing gut. The above was then repeated on the opposite side. The corneal protectors were removed with excellent size, shape and symmetry of her lids demonstrated. The eyes were irrigated with BSS followed by placement of Blephamide.
The fat was then harvested from the patient’s flanks using a Coleman fat harvesting needle. This was placed in 3 mL syringes and spun in a centrifuge. Lidocaine with epinephrine was placed along the nasolabial creases, the prejowl hollow and into the white roll of the lips. The spun fat was decanted of supernatant and then injected using a Coleman injecting needle in the nasolabial creases, the prejowl hollow and the white roll of the lips. The head and neck were cleansed. Polysporin and Xeroform were placed. The patient was then placed in a head wrap. All sponge and needle counts were correct x2. The patient was then transferred to the postoperative recovery room in stable condition.
