DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left nasal skin defect, status post Mohs resection of basal cell carcinoma.
POSTOPERATIVE DIAGNOSIS:
Left nasal skin defect, status post Mohs resection of basal cell carcinoma.
OPERATION PERFORMED:
Full-thickness skin graft from the left preauricular area used to close nasal skin defect.
SURGEON: John Doe, MD
ANESTHESIA: Local with intravenous sedation.
ESTIMATED BLOOD LOSS: 50 mL.
COMPLICATIONS: None.
FINDINGS: Left nasal cavity defect measuring 2.6 x 1.6 cm.
INDICATIONS FOR PROCEDURE: The patient is a pleasant (XX)-year-old male who was found to have 2 lesions on the left side of his nose. He underwent biopsies of this area, which were found to be consistent with basal cell carcinoma. The lesions were located over the nasal tip and left nasal ala, nearly confluent with each other. The patient recently underwent Mohs microsurgery and presents to me for further reconstruction of this area. Various reconstructive options were discussed with the patient, including full-thickness skin graft versus a nasolabial flap versus paramedian forehead flap versus granulation. After much discussion, the patient wishes to proceed with full-thickness skin graft. The risks and benefits of surgery were discussed with the patient and he wishes to proceed.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position. Ancef 1 g was given intravenously. Next, the head of the bed was turned 90 degrees in a clockwise fashion. The bandage was removed from the left nose and there appeared to be 2 nasal skin defects next to each other. The larger of the two was located along the left nasal tip and measured approximately 1 x 1 cm. The adjacent defect measured 8 x 8 mm. There was a 2 mm strut of intact skin between the two defects. Irrigated this area copiously with normal saline and scrubbed the defect with chlorhexidine brush in order to expose fresh bleeding tissue. Of note, the overall defect of the left external nose measured 2.6 x 1.6 cm. There was no exposure of cartilage or through-and-through defect into the interior nasal cavity. There appeared to be approximately 8 mm of distance between the alar rim and the edge of the wound defect. Next, we inspected the left preauricular region and there appeared to be adequate skin laxity. There was no evidence of skin lesions in this area. Therefore, we deemed this area satisfactory for full-thickness skin graft harvesting. We measured an area spanning 3 x 2 cm. We marked this area in an elliptical fashion and injected approximately 7 mL of 1% lidocaine with 1:100,000 epinephrine. The patient was then prepped and draped in sterile fashion.
Next, we began harvesting the left preauricular full-thickness skin graft by making skin incisions using a 15 blade. We then proceeded with dissection immediately in a subdermal plane with minimal fat along the skin graft. The full-thickness skin graft was removed in its entirety. We then placed it on a Silastic block and removed any remaining subcutaneous fat along the undersurface of the skin grafts. In order to obtain closure of the preauricular defect, we performed advancement flap anteriorly for approximately 1 cm in the subcutaneous plane. Next, irrigation was performed and hemostasis was obtained using bipolar cauterization. The preauricular defect was closed with 3-0 Vicryl in the subcutaneous layer and 5-0 fast-absorbing chromic suture along the skin.
We then directed attention towards the left nasal skin defect. As previously stated, the wound had been freshened with manual scrubbing. Given the fact that there was a narrow strip of skin between the two defects, we elected to sacrifice this region to create a uniform area for coverage with a full-thickness skin graft. Therefore, we removed the intervening 2 mm skin strut down to the subdermal plane. At this point, the full-thickness skin graft was then brought into the nasal defect and the skin was reapproximated using 3-0 nylon spaced approximately 6 mm apart. The suture was left along for closure over a bolster. In between the Prolene sutures, we also placed 5-0 fast-absorbing chromic suture for reapproximation of the nasal skin and full-thickness skin graft. Next, a Xeroform bolster approximating the size of the defect was brought into the field and secured using previously placed Prolene sutures. This was performed adequately and the bolster appeared to be nicely secured. At this point, the procedure was deemed satisfactory. The patient was turned over to the anesthesia team and emerged from intravenous sedation without complication.
