DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Open wound, left dorsolateral aspect of the foot.
POSTOPERATIVE DIAGNOSIS: Open wound, left dorsolateral aspect of the foot.
PROCEDURE PERFORMED: Split-thickness skin graft to the open wound from left lateral thigh; size of the graft is 5 x 5 cm.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 10 mL.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old Hispanic male who was involved in a motor vehicle accident and sustained an open wound on the dorsolateral aspect of the left foot. The patient also has a cuboid fracture. He was doing wet-to-dry dressing, and he was noted to have about 4 x 4 cm open wound with red granulation tissue. Decision was made to proceed with skin graft of that area.
DESCRIPTION OF PROCEDURE: The patient was given 1 g of Ancef in the preop area. The patient was brought to the operating room and placed in the supine position. The left lower extremity was then prepped and draped in regular sterile routine fashion.
The open area, which was about 4 x 4 cm, was clean and healthy with red granulation tissue. The edges were refreshened. The area was irrigated copiously with normal saline to be prepared for a skin graft. The lateral upper thigh was then cleaned with mineral oil. The dermatome was set up for 0.015 inches thick. About 5 x 5 cm split-thickness skin graft was taken from the left upper thigh.
The graft was then fenestrated with the 15 blade. The graft was fit on the open wound and was secured with 3-0 nylon. The Adaptic was put over the graft and a ball of cotton moistened with normal saline was placed over the Adaptic and was secured with tail of the 3-0 nylon. Dressing was then applied involving 4 x 4 over the cotton ball and sterile Webril. For the donor site, it was dressed with epinephrine mixed in gauze. The 4 x 4 and Ace wrap were placed.
The patient tolerated the procedure well and was taken to recovery in stable condition. A splint was applied to the left foot.
