DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Entropion.
2. Acquired traumatic defect, left orbital rim.
3. Retained hardware.
POSTOPERATIVE DIAGNOSES:
1. Entropion.
2. Acquired traumatic defect, left orbital rim.
3. Retained hardware.
PROCEDURES PERFORMED:
1. Canthoplasty.
2. Left orbital rim exploration, removal of hardware.
3. Application of bone allograft.
SURGEON: John Doe, MD
ANESTHESIA: General with 8 mL of 1% lidocaine with epinephrine.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMENS: None.
COMPLICATIONS: None immediate.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic male who was involved in an industrial accident, which caused a zygomatic fracture on the left. This was initially repaired, and he was left with some residual deformity and some collapse of the fragments. The patient has been operated once before in order to achieve balance in his face. He also complains of entropion and irritation of his conjunctiva with lash irritation. The patient signed written consent stating he understands the risks and benefits of the procedure, including persistent asymmetry, left eye lower lid malposition, bleeding and infection.
DESCRIPTION OF PROCEDURE: After explaining the potential risks and benefits of the procedure to the patient, written consent was obtained, and the patient was taken to the operating room by gurney, transferred to the operating table in supine position. Nasotracheal tube was placed, and general anesthesia was induced. The patient’s face was prepped with Betadine and draped in standard sterile fashion. We went through the old incision over the lateral canthus, releasing it, and some hypergranulation tissue was also removed with electrocautery. We dissected down to the lateral orbital rim and performed the cantholysis. We then exposed the orbital rim, and there was some retained hardware along the inferolateral rim and up over the ZF suture. This was removed as well as some scar overlying it.
Next, we then burred a hole through the lateral orbital rim and passed a 3-0 Ti-Cron through, tied this down and then passed each needle through the upper and lower lid and tied them back down at the fornix, and thus performed the canthoplasty. The gray lines were then aligned with a 6-0 fast gut suture. A 3-0 Vicryl was placed deep and the lateral orbital rim defect was contoured by application of DBX bone allograft. We then closed the remainder of the incision with a 3-0 Vicryl and running 6-0 fast gut. At the end of the procedure, the patient had adequate tightness of the lower lid, and it was irrigated thoroughly with balanced salt solution, and ophthalmic bacitracin was applied over the incisions. The patient tolerated the procedure well without any immediate complications. He was extubated and taken to PACU.
