DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Eyebrow ptosis.
2. Eyelid ptosis.
3. Upper lid fat prolapse.
4. Dermatochalasis.
POSTOPERATIVE DIAGNOSES:
1. Eyebrow ptosis.
2. Eyelid ptosis.
3. Upper lid fat prolapse.
4. Dermatochalasis.
OPERATION PERFORMED:
1. Bilateral direct brow lift.
2. Bilateral upper lid ptosis repair.
3. Bilateral upper lid blepharoplasty.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA:
1. IV sedation.
2. Local 2% lidocaine with 1:100,000 epinephrine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: In the preoperative holding area, the entire procedure was reviewed. All questions that the patient had were answered regarding the risks, benefits, and alternatives to the procedure, and the patient wished to proceed with the surgery. An upper lid supraciliary incision was made in the brow in a lazy-S fashion. The brow was elevated, the pen positioned, the brow dropped, and the upper incision line was marked. The patient was brought to the operating room theater and prepped and draped in the normal sterile fashion for facial plastic surgery. IV sedation was administered, and when it was adequate, local anesthetic was infiltrated. Since the procedure was identical for both sides, it will be described for only one side.
The skin incision was made with a #15 blade, and the brow and subcutaneous fat was removed with cutting cautery in the supramuscular plane. Hemostasis was secured. The incision was closed with interrupted 4-0 Vicryl suture and a running tie-over horizontal mattress suture of 5-0 nylon.
Attention was turned to the upper lids. The lid crease incision was sketched using the pinch technique with a slight brow depression. The upper incision line was determined. Again, local anesthetic was infiltrated. The skin was incised with a 15 blade and cutting cautery used to go through the orbicularis muscle, and the skin muscle flap was then removed. With downward tension on the lid, the septum was opened and orbital fat identified.
Further supplemental anesthetic was given, and the sub-brow and orbital fat was then excised with cautery. Hemostasis was secured. Levator aponeurosis was then supported with a 6-0 Prolene. The level of the lids was checked until they were totally deemed adequate, and when they were with good symmetry and adequate elevation, the skin incision was closed with running 6-0 fast-absorbing gut suture. TobraDex ointment was applied. There were no complications. The patient tolerated the procedure well and went to the postoperative recovery room and home in good condition.
