DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Congenital deformity, nasal tip.
2. Acquired deformity of back.
3. Acquired deformity of abdomen.
4. Deformity of left lower eyelid.
5. Facial rhytids, including right oral commissure.
POSTOPERATIVE DIAGNOSES:
1. Congenital deformity, nasal tip.
2. Acquired deformity of back.
3. Acquired deformity of abdomen.
4. Deformity of left lower eyelid.
5. Facial rhytids, including right oral commissure.
OPERATIONS PERFORMED:
1. Back lift with liposuction.
2. Abdominal liposuction.
3. Tip rhinoplasty.
4. Revision, left lower eyelid blepharoplasty.
5. Autologous fat injection to right oral commissure for facial rhytids.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PAC
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 150 mL.
SPECIMEN SENT: None.
DRAINS: Jackson-Pratt x2, Foley to gravity.
COMPLICATIONS: None.
FLUIDS: Approximately 2100 mL of tumescent fluid.
DESCRIPTION OF OPERATION: After identification of the patient and obtaining informed consent, in the preoperative holding area, we marked the left lower eyelid for a 2 mm excision of redundant skin at the left lower eyelid and the medial and sagittal fat compartments where there was some redundant fat, which had remained, marked out the oral commissure and the area lateral to it where there was some excessive fat on the right side of her face. We marked out the planned incision on her back and areas of liposuction in the upper abdomen, central abdomen, and along the lateral flank areas and outer hip.
The patient was taken to the operative suite and placed on the table. She underwent induction and intubation of general anesthesia and was placed in the prone position over adequate padding and jelly rolls. A Foley catheter was placed by the nursing staff. First, sequential pressure stockings were placed. DVT prophylaxis and antibiotic prophylaxis were given. The back was prepped and draped in the usual sterile fashion using Betadine scrub and paint.
Through four small puncture incisions in the lower back, we injected a total of 1100 mL of tumescent solution. The tumescent solution consisted of 3 liters of saline mixed with 3 mL of epinephrine 1:100,000 and 60 mL of 1% lidocaine plain. We liposuctioned out approximately 1 liter of liposuction aspirate from the back and lateral truncal areas. Then, we performed the upper abdominal back incision, elevated skin and subcutaneous tissues off the back and musculature superiorly to the level of the scapula and pulling it down just to find how much we could remove without undue tension on the closure.
We performed a V-shaped incision in the upper buttock region down to, but not involving, the gluteal cleft. We then excised the redundant skin and subcutaneous tissues, the weight of which was approximately 530 grams. The area was irrigated with saline-containing bacitracin. Attention was paid to hemostasis with electrocautery. We then brought the V together into a straight line closure along the upper buttock area in layers using 0 Vicryl sutures.
We brought the upper back skin down and realized that there was redundant tissue centrally and excised the V-shaped excision superiorly. We closed this in layers using 0-Vicryl sutures. We closed the Scarpa fascia with 0 Vicryl sutures, the subdermal tissues with 2-0 Vicryl sutures and skin edges with 4-0 PDS. Prior to closure, two #10 flat JP drains were inserted underneath the flaps and brought out through separate stab incisions laterally. Mastisol, Steri-Strips, and sterile dressings were placed.
The patient was placed in supine position. The abdomen was then prepped and draped in sterile fashion with Betadine scrub and paint. A small puncture incision was made in the supraumbilical region and along the lower abdomen. Tumescent solution was injected including a total of 1.1 liters.
We then liposuctioned out approximately 950 mL of liposuction aspirate from the upper abdomen, central abdomen, lateral abdominal areas, and the flank and outer hip regions. About 20 mL of the fat was saved, cleansed with saline-containing bacitracin, decanted, and used for later autologous fat grafting. We closed the liposuction puncture sites with 5-0 Prolene sutures in a horizontal mattress suture fashion. Sterile dressings were applied.
The face was prepped and draped in the usual sterile fashion using pHisoHex. We took an 18 gauge needle and tuberculin syringe and injected approximately 1.75 mL into the right lower commissure, the white vermilion, and along the right side of the lower lip and then liposuctioned after induction of local analgesia the redundant fatty tissue lateral to the area through the small puncture incision in the oral commissure.
This incision was closed with 6-0 Prolene suture. Then, along the left lower eyelid, we injected 1% lidocaine with epinephrine. A subciliary incision was performed. Skin and orbicularis were elevated down to the level of the orbital rim. We removed some remaining redundant scar tissue and fatty deposits in medial and central fat compartments. We removed 2 mm of skin and orbicularis muscle. We performed a canthopexy laterally with 5-0 PDS suture, approximating it to the periorbital fascia. We closed the incision with 6-0 Prolene sutures in interrupted fashion, confirming that there was no scleral show and no undue tension on the closure.
Along the nose, we injected 1% lidocaine with epinephrine. We used pledgets with Neo-Synephrine, prior to this, inside the nose and these were removed. We injected the nasal vestibule with 1% lidocaine with epinephrine. We performed incisions extending down to the caudal septum, then elevated the alar cartilages contained on the underlying mucosa of the nose, elevating up to the alar dome, separating from the attachment to the upper outer cartilages.
We performed a resection of 2 mm of cephalic trim of the alar cartilage on each side. It was completely freed up, and we performed two intradermal sutures with 5-0 PDS to bring the boxy tip together and then, after being satisfied with the symmetrical result, we closed the incision in layers using 5-0 chromic sutures in each side. The nose was then taped with Steri-Strips. TobraDex was applied to the left lower eyelid. A binder was placed around the patient. The patient was extubated and taken to the recovery room in stable condition. There were no complications.
