DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Absent breasts, bilateral following mastectomies.
POSTOPERATIVE DIAGNOSIS: Absent breast, bilateral, following mastectomies.
OPERATION PERFORMED: Bilateral breast reconstruction with TRAM flaps.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATION FOR OPERATION: This (XX)-year-old Hispanic female has previously undergone double mastectomies for cancer. She is free of disease and is here for reconstruction.
FINDINGS AND DESCRIPTION OF OPERATION: The patient’s chest wall was marked with her in a sitting position in the holding area. She was then brought to the operating room and placed on the OR table in supine position. General anesthesia was induced. Foley catheter was placed in the bladder, and sequential compression devices were placed in the lower extremities.
An incision was made in the left and right sides of the anterior chest wall, and skin flaps were elevated. Elevation was made at the level superficial to each pectoralis major muscle. A periumbilical incision was then made with #15 blade, and the umbilicus was dissected from surrounding soft tissue with Metzenbaum scissors. A 10 blade was then used to make a long transverse abdominal wall incision at the level of the umbilicus. Electrocautery dissection was carried down to the anterior rectus sheath, and a large apron of skin fat and fascia was elevated. A subfascial tunnel was created to the pockets created on either side of the anterior chest wall.
A 10 blade was then used to make a longitudinal incision over the anterior rectus sheath, one incision directly over each rectus abdominis muscle. Electrocautery was used to dissect each muscle from its investing fascia. Once each muscle was completely freed from investing fascia, a long transverse incision was made in the lower abdominal wall, thereby completing the skin paddle. Dissection was carried down to the level of the anterior rectus sheath. The lateral aspects of the large transversely oriented paddle were then elevated with electrocautery until the mid level of each muscle was reached. The fascial cuts were completed with a 10 blade, and each inferior epigastric artery and its accompanying veins were isolated and ligated with 2-0 silk suture. The insertion of each rectus abdominis muscle was then divided with electrocautery, and the flap was then completely freed from investing fascia. A central strip of rectus abdominis muscle fascia was preserved to help facilitate abdominal wall reconstruction. The flap was then bisected in the midline, thereby creating two separate breasts flaps. Each was gently passed through its subfascial tunnel to the chest wall.
The flaps were then appropriately trimmed and de-epithelialized. Each was then sutured in place over a 7 mm flat JP drain using 3-0 Vicryl and 4-0 PDS in the deep dermal and subcuticular dermal layers respectively. The abdominal wall was then reconstructed in this patient using large pieces of AlloDerm. The anterior rectus sheath was repaired in the upper abdominal wall using #1 Prolene suture. When the lower abdominal wall area was reached, where there was missing fascia from flap transfer, AlloDerm was used for the repair of the fascia. This was secured in placed with Prolene suture.
The patient’s bed was placed in extremely flexed position with head of bed elevated, and flap closure was completed using 2-0 Vicryl in Scarpa fascia, 3-0 Vicryl in the deep dermal layer and 4-0 PDS in subcuticular dermal layer. The umbilicus was brought out the central portion of the abdominal wall through the small transverse incision, and the umbilicus was anchored to surrounding skin using 3-0 Vicryl in the dermal layer and 5-0 nylon in the epidermis. Two Jackson-Pratt drains were placed in the abdominal wall prior to closure and brought out the suprapubic area through stab incisions. Once closure was completed, the patient was transferred very carefully to her hospital bed, wearing an abdominal binder and a surgical bra. Estimated blood loss was 300 mL. No complications.
