DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Prominent nose, neck lipodystrophy, and abdominal lipodystrophy and laxity.
POSTOPERATIVE DIAGNOSES: Prominent nose, neck lipodystrophy, and abdominal lipodystrophy and laxity.
OPERATIONS PERFORMED: Rhinoplasty, suction-assisted lipectomy of the neck, and abdominoplasty with liposuction.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Approximately 100 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was seen in the preoperative area. While in the standing position, the abdomen was wiped with alcohol and marked with a marking pen for surgery as well as suctioning. Then, in the sitting position, the nose as well as neck were wiped with alcohol and marked with a marking pen for surgery. The patient was brought into the operating room, placed supine on the operating room table, and administered general anesthesia successfully. A total of 6 mL of local anesthetic mixture was injected into the nasal skin as well as into three liposuction access site incisions of the neck. Neo-Synephrine dampened cottonoid pledgets were placed bilaterally. The outer eyes were taped. The face and neck were prepped and draped in the usual sterile fashion. An incision was then performed on the inner aspect of the alar rim, on each side at the lower border of the alar cartilage as a rim incision, and then scissor separation proceeded with tenotomy scissors, followed by cautery, and Q-tip applicators to separate the soft tissue up off the lower lateral alar cartilages. A 4.5 mm rim strip was then marked and then cephalic alar resection was performed bilaterally. Soft tissues were elevated up off the dorsum as well as caudal aspect of the septum.
A 1.5 mm segment of the caudal septum was then excised, tapering back towards the mid aspect of the caudal septum. A #5 gold handle rasp was then used to rasp down the bony aspect of the dorsum and then cartilage rasp was used to take down the cartilaginous aspect of the dorsum to make it smooth. Hemostasis was obtained with cautery. The field was irrigated with saline solution. A 5-0 Vicryl suture with a tapered needle was then used to approximate the inner aspect of the alar domes to reduce the broadness of the nasal tip. The alar cartilages were put back into position and closure was completed with 5-0 chromic interrupted sutures on the mucosal side. Stab incisions were then performed x3 in the neck and dilated with hemostat, and tumescent solution was infiltrated throughout the subcutaneous plane for a total of 150 mL with a standard mixture of 20 mL of lidocaine and 1 mL of adrenaline per liter of warm lactated Ringer’s.
Suctioning was then performed through the submental incision initially, fanning outward and then through each of the lateral incisions just behind the base of the ear lobe, crossing towards the anterior aspect of the neck. At all times, we kept the cannula parallel to the skin surface and just deep to the skin surface, so we could feel it and see it to prevent platysmal penetration. Good reduction was noted. Output was approximately 75 mL. Incisions were closed with 6-0 Prolene interrupted sutures. Band-Aids applied. Gauze dressings were then later applied and followed by neck garment. On the nose, it was cleaned, dried, and dressed with benzoin and Steri-Strips and AlumaFoam splint for compression.
Attention was turned to the abdomen. Local anesthesia was infiltrated x10 mL along the abdominoplasty incision as well as the two liposuction incisions in the low lateral flank. The entire abdomen was prepped and draped in the usual sterile fashion. We had previously placed Foley catheter after induction. The stab incisions were then made x4. Tumescent solution was infiltrated throughout the subcutaneous plane with standard mixture of 20 mL of lidocaine, 1 mL adrenaline per liter of warm lactated Ringer’s for a total of 1830 mL. Suctioning was then performed with the 4 mm cannula throughout the entire anterior as well as lateral abdomen with total output being 2100 mL.
The patient was extremely prominent in the upper abdomen with a very deep supraumbilical crease. We made a small incision in the high upper abdomen and then suctioned superficially the soft tissue overlying the ribs and central tissue just staying superficially with a 2 mm cannula in order to thin out some of the prominence of the upper abdominal fat fold. This incision was closed with 5-0 Prolene single suture. Same sutures were then used to close the lateral aspect of the liposuction incisions. The circumcision was then performed around the umbilicus, stalk was dissected free from the surrounding fat. A V-shaped incision was then performed on the lower abdomen and carried down to the subcutaneous plane and fascia with cautery. The skin and fat apron flap was then developed on top of the abdominal wall fascia, narrowing as we got up towards the epigastrium, staying approximately an inch away from the costal margins. There was minimal diastasis. The laxity of the abdominal wall was marked with pen and running fascial plication was then performed with #1 TiCron suture, both separate sutures brought down beneath the umbilicus and interrupted sutures being placed every 2 cm. Through the groin stab incision at each side, 10 mm Jackson-Pratt drains were brought through on each side, cut to appropriate length, and sutured in placed with 2-0 silk drain sutures.
The back of the bed was brought up to 50 to 60 degrees. Access was marked approximately 3 cm above the umbilical defect, cut across, and down towards the crest incision. It was resected finally with cautery. Total weight of the panniculus was 2250 grams. It was discarded. Abdominal field was irrigated with bacitracin solution. Hemostasis was obtained with cautery. The abdominal incision was temporarily approximated with staples for alignment. Closure was then completed in layers with 3-0 Vicryl interrupted suture in the deep subcutaneous fascia with interrupted sutures done in the rectus fascia, followed by 3-0 Vicryl buried inverted suture in the subcutaneous and deep dermis, and running 4-0 PDS mid-dermal subcuticular repair, one on each side. Oval shaped incision of the skin was then preformed over the umbilical prominence, and fat was cored out beneath this. Umbilicus was brought through the incision and placed with 3-0 Vicryl suture, running 5-0 nylon repair.
The sites were all cleaned with saline solution and dried and dressed with benzoin and Steri-Strips on the lower abdominal incision. Polysporin and Adaptic on the umbilicus. Band-Aids on the lateral liposuction incisions. Gauze dressings, ABD pads, and binder were all applied. Neck garment applied to the neck. The patient tolerated the procedures well with no apparent complications. The patient was then extubated in the operating room and transferred to the recovery room in satisfactory condition.
