DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Skin cancer of the nose.
POSTOPERATIVE DIAGNOSIS: Skin cancer of the nose.
OPERATION PERFORMED:
1. Wide local excision of 1 cm nasal tip skin cancer.
2. Banner local flap for closure.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Monitored anesthesia care with IV sedation and local.
ANESTHESIOLOGIST: Jane Doe, MD
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old female who presented with biopsy-proven skin cancer of the nasal tip. Because of its location and need for frozen sections, the patient was brought to the operating table where Pathology could give us frozen section results.
OPERATIVE FINDINGS: Free margins with residual tumor. A second, extended margin of the deep layer was taken, which showed free margins as well.
DESCRIPTION OF OPERATION: After obtaining written consent, which included but was not limited to infection, bleeding, scars, deformity of the nose, loss of part or all of the skin flaps, recurrence of tumor, and need for further surgical revisions, the patient understood, and all of her questions were answered. The patient gave full consent to proceed.
The patient was previously marked at the dermatologist’s office where biopsy had been taken. She was brought to the operating table and examined under loupe magnification. This indeed showed residual area of biopsy site. This was infiltrated with 1% lidocaine with epinephrine after induction with IV sedation with monitored anesthesia care and monitoring. She was then prepped and draped in the usual sterile fashion. Wide local excision of a 1 cm area was excised and sent to Pathology. The margins showed free tumor; however, there were some close cells deep to the deep margin. A second extended margin of deep tissue was taken, which showed no tumor.
A local banner flap was then elevated and placed into the defect. It was inset with interrupted 5-0 and 6-0 nylon sutures. Undermining was performed to allow easy closure of the donor site. Dressings were applied. The patient was brought to the recovery room in stable condition.
