DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Aesthetic deformity of face.
POSTOPERATIVE DIAGNOSIS: Aesthetic deformity of face.
OPERATIONS PERFORMED:
1. Bilateral lower eyelid blepharoplasty.
2. Open rhinoplasty.
3. Fat transfer to bilateral nasolabial folds.
SURGEON: John Doe, MD
ANESTHESIA: General with endotracheal tube.
ESTIMATED BLOOD LOSS: 80 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was marked in the upright position and was given intravenous antibiotics. The patient was subsequently taken to the operating room and placed in the supine position. Bilateral sequential compression boots were applied and the patient was placed under general anesthesia without difficulty. The face and central lower abdomen were then prepped and draped in the usual sterile manner.
We first performed the bilateral lower eyelid blepharoplasty. The bilateral lower eyelids were infiltrated with 1% lidocaine with epinephrine. We first worked on the right side. A subciliary incision was made with a #15 blade. Bleeding points were controlled with cautery. A skin-muscle flap was then raised to the level of the inferior orbital rim. The orbital septum was identified. Three small incisions were made in the medial, central and lateral aspects of the septum. The herniating fat pads from all three compartments were then removed with cautery without difficulty. Care was taken to avoid over-resection of these compartments. The skin-muscle flap was then redraped. Inferior traction was placed on the cheek and superior traction was placed on the eyebrow. A 2 mm wide aspect of the skin-muscle flap was then excised without difficulty.
We then moved to the left side. The mirror image subciliary incision was made with a #15 blade. Bleeding points were controlled with cautery. The skin-muscle flap was then developed to the level of the inferior orbital rim. The orbital septum was visualized and small incisions were made in the medial, central and lateral aspects of the septum. The fat pads were isolated in these areas and a similar excision was performed with cautery. Care was taken to avoid over-resection of these areas. After meticulous hemostasis had been achieved, the skin-muscle flap was redraped. Inferior traction was placed on the cheek and superior traction was placed on the eyebrow. A 2 mm strip of the skin-muscle was excised without difficulty. Both eyelid incisions were then closed with interrupted deep 5-0 Vicryl suture for the muscle followed by a running intradermal 6-0 Prolene suture for the skin. Steri-Strips were used to affix the edges of the suture.
We then performed fat harvesting from the central lower abdomen. A 4 mm incision was made in the central pubic area. Tumescent solution containing 30 mL of 1% lidocaine and 1 ampule of epinephrine/liter of normal saline was utilized. A total of 300 mL was infiltrated into the central lower abdominal subcutaneous tissue. After approximately 10 minutes, syringe-assisted liposuction was performed in this area. Approximately, 100 mL of aspirate was removed. The aspirate was then placed into separate 10 mL syringes and was centrifuged for about 24 minutes. The abdominal incision was closed in one layer with interrupted 5-0 Prolene suture and sterile gauze dressing, and Tegaderm was then applied.
We then performed the open rhinoplasty. The nose was infiltrated with 20 mL of 1% lidocaine with epinephrine and the mucosal membranes were packed with 5% cocaine to facilitate vasoconstriction. A #15 blade was then used to make bilateral intercartilaginous incisions. These incisions were then connected with a transcolumellar incision performed in a stair-step manner. Low cautery was used to control bleeding points. The skin and soft tissue envelope was then elevated off the underlying lower lateral cartilages bilaterally with iris scissors. The skin envelope was also elevated off the upper lateral cartilages and off the nasal bone as well. Hemostasis was then achieved.
We first worked on the lower lateral cartilages. These cartilages were quite prominent and therefore cephalic trim was planned. The caudal 6 mm of cartilage was preserved bilaterally. The remaining portion was dissected off the posterior mucosal membranes and was then excised with sharp iris scissors. At this point in time, we performed bilateral nasal bone osteotomies to shift the nasal pyramid inward to decrease the nasal width. These osteotomies were performed intranasally with 2 mm osteotomes in a low-to-low manner. The osteotomies were performed without difficulty and the bones were shifted inward without difficulty. At this point, the tip complex was re-analyzed and was found to have a deviation towards the patient’s right. Therefore, we planned to harvest septal cartilage to create a columellar strut. The lower lateral cartilages were retracted caudally and laterally. The anterior septal angle was exposed and bilateral mucoperichondrial flaps were elevated.
The entire septum was exposed and the submucous cartilage resection was performed. An L-strut was preserved which was 1 cm wide throughout. The remaining septum was excised sharply with a #15 blade and a swivel knife. The cartilage was then harvested and then cut to create a columellar strut graft measuring 3 x 25 mm. This strut graft was then placed in a soft tissue pocket between the medial crura of the lower lateral cartilages. The medial crura were then sutured with clear 4-0 PDS suture to the strut graft. At this point, the patient’s dorsal hump was reduced with a combination of dorsal rasping and direct excision. The dorsal hump was taken down about 4 mm to create a nice dorsal profile to the nose. Finally, the middle crura were plicated to one another to narrow the tip further and to auto-rotate the tip upwards to about 2 mm.
The skin and soft tissues were then redraped over the nasal framework and all edema was squeezed out of the nose. It was found to have a good contour at this time. All internal incisions were closed with interrupted 5-0 chromic sutures. The transcolumellar portion of the incision was then closed with interrupted 6-0 Prolene suture. Internal nasal packings were placed bilaterally, which consisted of Adaptic coated in bacitracin ointment. An external Denver splint was also applied.
We then injected approximately 10 mL of fat into the nasolabial folds bilaterally. The initial labial folds were diminished in prominence after this was performed. The patient tolerated the procedure very well, was extubated without complication and transferred to the recovery area in good condition. The patient will go home today with prescriptions for both antibiotics and pain medications. The patient will then follow up with me in the office again tomorrow for evaluation and internal packing removal.
