DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right unilateral symptomatic gynecomastia.
POSTOPERATIVE DIAGNOSIS: Right unilateral symptomatic gynecomastia.
OPERATION PERFORMED: Right partial mastectomy.
SURGEON: Jane Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Approximately 20 mL
DESCRIPTION OF OPERATION: The patient was seen in the preoperative holding area. While in the standing position, the patient’s right unilateral gynecomastia as well as pertinent anatomy was marked with the surgical pen. The patient received 2 grams of Ancef preoperatively. Bilateral SCDs were placed for DVT prophylaxis. The patient was then brought back to the operating room suite and placed supine on the operating table. After induction of general anesthesia, the patient’s chest was prepped with Betadine and surgically draped. Then, 30 mL of 0.5% lidocaine with epinephrine was infiltrated into the patient’s soft tissue on the right breast.
After adequate time had transpired, a right circumareolar incision was made with a #15 blade scalpel. Dissection continued, first preserving a 1 cm cuff below the right nipple-areolar complex as well as a superiorly-based pedicle. Breast flaps were developed sharply under direct vision. Redundant breast tissue was then removed down to the anterior pectoralis major muscle fascia circumferentially. Hemostasis was achieved with electrocauterization. Irrigation of the pocket was then performed. The specimen was passed off the operative field and sent to Pathology for further analysis. A #10 JP was placed into the breast pocket and secured to the skin level with a 3-0 nylon suture and placed to bulb suction. Tisseel fibrin sealant was then introduced into the cavity according to the company’s recommendations.
The remaining breast tissue was reapproximated with several interrupted 4-0 Vicryl sutures followed by deep dermal reapproximation with 4-0 Vicryl sutures. The remaining skin was closed with running 4-0 intracuticular nylon sutures followed by benzoin and quarter-inch Steri-Strips. A sterile compressive dressing was then placed around the patient’s right breast. The patient tolerated the procedure well. Estimated blood loss was approximately 20 mL. All sponges and needle counts were correct. There were no complications. The patient was subsequently extubated in the operating room and transferred to the recovery room in stable condition.
