DATE OF SURGERY: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.
POSTOPERATIVE DIAGNOSIS: Absent left breast status post mastectomy for cancer, previous infected implant.
SURGERY PERFORMED: Left breast reconstruction with placement of subpectoral implant and pocket adjustment (extensive capsular release).
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia with LMA.
COMPLICATIONS: None apparent.
ESTIMATED BLOOD LOSS: Less than 50 mL.
DRAINS AND TUBES: A 7 mm Jackson-Pratt drain.
SPECIMEN: Removed expander, discarded. Left breast implant capsule for culture and sensitivity (aerobic, anaerobic, AFB and fungal).
IMPLANT: McGhan 363LF implant with 450 cc of saline added.
INDICATIONS FOR SURGERY: The patient is a (XX)-year-old female who is status post bilateral mastectomies for cancer, reconstructed with subpectoral expanders and implants. Unfortunately, the implant on the left side had clinical infection, although no positive cultures, and had to be removed.
The tissue has now settled down and now for replantation with the major concern being additional infection and also scar. Options considered including replacement of an expander or using a Mentor adjustable implant. However, concern would be that if we do not get adequate reconstruction, the scar tissue is going to be the major limiting factor and would need additional vital tissue, latissimus flap, to permit adequate reconstruction.
Given the risk of infection, we planned to irrigate with both Ancef and kanamycin as bacitracin was not available. In addition, given preoperative Timentin, and we will use Augmentin postoperatively. A drain will be placed.
DESCRIPTION OF SURGERY: The patient was taken to the operating room for left breast reconstruction and was placed in the supine position on the operating table whereupon all appropriate monitoring equipments were attached. At this point, general anesthesia with LMA was uneventfully introduced. Timentin was given intravenously.
The patient had been marked in the preoperative holding area in a sitting position as to the planned lines of the pocket creation and these marks of course were left in place. The entire operative site was then prepped with Betadine in the usual manner, and sterile drapes were applied in the usual fashion. With excellent illumination, including lighted breast retractor and loupe magnification, the left breast reconstruction was undertaken.
The previous left lateral incision just above the inframammary fold was used, and deeper dissection was done with a Bovie cautery device maintaining meticulous hemostasis at this point and throughout the entire procedure. There was some vigorous bleeding along some of the scar tissues, but it was easily controlled with the cautery.
We did dissect underneath the pectoralis and soon came to the previous pocket. This was then enlarged to the marks coming to the lateral border of the sternum, the inframammary fold, anterior axillary line, and then superiorly as well. The periphery being well open, the overlying scar tissue of the capsule was now opened with moldable “postage stamp” dissections until by palpation it was completely released to allow good expansion over the implant.
The pocket was again examined and a portion of the lateral pocket along the chest wall was excised, cut into small sections and sent for culture. No purulence, unhealthy tissue, masses or any other abnormalities were seen beyond the scar.
The #3-0 Vicryl sutures were placed along the capsular opening at the incision and left long to tie down over the implant once placed.
The pocket was copiously irrigated with saline plus Kantrex and Ancef after a 7 mm Jackson-Pratt drain had been placed through the previous stab wound laterally inferiorly and sutured to the skin with #3-0 Vicryl.
Re-inspection was unremarkable, no active bleeding.
The implant was prepared on the back table with all air evacuated and 50 cc of saline added. The implant was now put in position and inflated up to 500 cc, the volume of the right side, and then after about 2-1/2 minutes, it was backed down to 450 cc which had been the equalizing point earlier. That seemed to give a good volume match to the right side but again concern was related to the scar and how well the tissue will re-drape to allow good breast reconstruction.
The fill valve was removed and the seal placed. The #3-0 Vicryl sutures were tied down. Additionally, a #3-0 Vicryl was placed to the subcutaneous layer and then a subcuticular #4-0 Vicryl. Steri-Strips over Mastisol completed the closure.
The entire area was cleansed and dressed with ABDs and bra. No abnormalities were seen in the skin, except for scars.
The left breast reconstruction being done, anesthesia was also ended. The patient was then escorted to the recovery area having tolerated the procedure and the anesthesia in a satisfactory condition. Written instructions were provided. She already has a prescription for Augmentin and Lortab. Followup has been arranged for next week. The patient was specifically instructed to call if there are any questions or problems.
