DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Cervicofacial papules.
POSTOPERATIVE DIAGNOSIS: Cervicofacial papules.
PROCEDURE PERFORMED: Excision of papules, cervicofacial, with primary closure.
SURGEON: John Doe, MD
ANESTHESIA: Local.
ESTIMATED BLOOD LOSS: Scant.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the semi supine position. Each site was prepped and draped separately. The right neck was treated first. A 2-layer Betadine swab prep was employed. A blue drape with a central cut-out was placed over the papule. The papule measured approximately 6.5 mm. It had an irregular surface that was not truly papillomatous. A marking pen was used to map out the elliptical incision plane. Lidocaine 1% with 1:100,000 units of epinephrine was used as the anesthetic agent. The site was injected with approximately 2 mL of fluid, one from the medial and one from the lateral aspect. A 27 gauge needle was used. Gentle massage then followed to facilitate uptake of the medication by the tissues. A 15 blade was used to make the incision surrounding the papule. It followed the delineation of the marking pen. The edges laterally and medially were approximated. Forceps was used to grasp the normal skin, allowing the 15 blade to dissect into the subcutaneous tissue plane. The patient tolerated the excision without additional need for anesthetic. Once the subcuticular tissue plane was reached, the excision continued from medial to lateral with tension held on the specimen to be removed. There was no gross evidence of extension of the disease to the undersurface of the excised tissue. The specimen was removed from the field in its entirety and placed in formalin. This was delivered to the laboratory for analysis. Grossly, the skin margins were free of disease. Given the benign nature of the condition, approximately 2 mm was used as a superior-inferior margin. Hemostasis was achieved with a needle-tip cautery at 5 watts of coag power. The device had an overlying protector to avoid any inadvertent injury to other skin areas. Due to the elliptical nature of the excision and its small vertical dimension, easy primary approximation was achievable. This was performed using 4-0 Prolene suture. A midline dissecting suture and 2 subsequent sutures were placed.
The left cervical papule was next addressed. It was prepped and draped. Again, the marking pen was used to establish an elliptical and horizontal incision. The anesthetic was injected. An additional 1.5-2 mL was used. The same technique was employed to excise the papule and to close the tissue bed. Attention was next directed to the right temporal region. Again, a 2-layer Betadine prep was performed followed by placement of a sterile towel. The same method was employed with use of a marking pen to delineate the intended elliptical incision by injection of the anesthetic. This papule was nonpigmented on gross appearance. The excision was performed in a manner similarly described as above. Incision was brought down through the cutaneous region to the subcutaneous tissue plane. No nerve trunks or vessels were noted that warranted isolation or ligature. Following removal, the wound was again closed with interrupted 4-0 Prolene suture.
The final site to be addressed was the right nasal alar mass. This was firm and did not have the same rugae surface as the other sites. Following use of the marking pen, the upper lip and right nostril region were injected with anesthetic. The nurse’s report contains total use of the anesthetic throughout the procedure. More significantly, the incision was not elliptical, but curvilinear, to follow the contour of the ala. A fresh 15 blade was used. This papule had more of a fibromatous component. It was also embedded deeper than the other specimens. Once the lower curvilinear incision was made, the superior one, contouring the inferior aspect of the ala was performed. The incision was again brought down through the skin to the subcutaneous tissue plane. This was then dissected from the underlying soft tissues. Although benign in appearance, on palpation, the superficial mass had deep extension. The base was transected below this plane. The remaining soft tissue attachments were transected to allow for removal of the specimen from the field. It too was placed in formalin.
Electrocautery was used for hemostasis. Pressure was also applied. Due to the degree of dead space, a single buried 4-0 chromic suture was placed. This allowed for 4 separate 4-0 Prolene sutures to be placed with the intent to achieve eversion. This was satisfactorily achieved. The patient’s face and neck were cleaned with a wet and dry gauze at each surgical site. Bacitracin ointment was applied. The procedure was deemed complete. After a suitable period of observation, the patient was discharged home.
