DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Bilateral upper extremity skin and adipose tissue excess following weight loss, following gastric bypass surgery.
2. Postpartum and post weight loss abdominal wall laxity and skin excess.
3. Diet and exercise resistant adipose tissue abdominal wall and iliac crest regions.
POSTOPERATIVE DIAGNOSES:
1. Bilateral upper extremity skin and adipose tissue excess following weight loss, following gastric bypass surgery.
2. Postpartum and post weight loss abdominal wall laxity and skin excess.
3. Diet and exercise resistant adipose tissue abdominal wall and iliac crest regions.
OPERATION PERFORMED:
1. Bilateral brachioplasty and lipoplasty, upper arms, utilizing Ted Lockwood technique.
2. High-lateral-tension abdominoplasty with lipoplasty of abdominal wall and iliac crest regions, Ted Lockwood surgical technique.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who presents for bilateral brachioplasty and lipoplasty of the upper extremities as well as high-lateral-tension abdominoplasty with rectus muscle sheath plication and lipoplasty of the abdominal wall and iliac crest regions for treatment of post gastric bypass weight loss and postpartum abdominal wall laxity, as well as diet and exercise resistant adipose tissue.
OPERATIVE FINDINGS AND PROCEDURE: In the presurgical holding area, markings were undertaken of the bilateral upper extremities as well as the abdominal wall and iliac crest regions for the above-described surgical procedures. Next, a peripheral IV was initiated by the presurgical nurse, and prophylactic antibiotics were administered. Next, bilateral TED hose and SCD hose were placed. The patient was transported to the operating room where the SCD hose was connected to the SCD pump. Padding was placed beneath the knees, padding to the upper extremities and a gel pad to the head. Next, after induction of general anesthesia, a Foley catheter was placed by the circulating OR nurse.
Attention was then directed toward the upper extremities. Two surgical arm tables were then placed. The upper extremities were then prepped and draped in the usual sterile manner, including the axillae and the upper chest wall. Attention was first directed toward the right upper extremity. Used the presurgical markings. These markings were reinforced after surgical prep and lidocaine 1% with epinephrine 1:100,000 mixed equally with 0.25% Marcaine with epinephrine 1:200,000 was used to infiltrate the incision sites.
Next, utilizing a 5 mm incision just proximal to the olecranon, a subcutaneous plane was created and lipoplasty was undertaken after superwet solution consisting of 1 liter of lactated Ringer’s, which was at 1 mL of epinephrine 1:1000 concentration and lidocaine 1%, 3 mL. Approximately 300 mL of lipoplasty solution was infiltrated. Lipoplasty was then undertaken utilizing 3 and 4 mm round 3-hole and a 4 mm flat 2-hole lipoplasty cannula. Following completion of lipoplasty, the surgical flaps were elevated in the subcutaneous plane and excision and rotation and advancement of the skin was undertaken both transversely as well as in the axillary regions.
The SFS sutures utilizing 2-0 PDS were placed followed by sutures of 3-0 undyed Monocryl in 2 layers for the deep dermis and subcuticular planes. A similar procedure was undertaken for the left upper extremity. Supernatant fat removed bilaterally, approximately 450 mL. The incisions were then dressed with Xeroform gauze, 4 x 4 gauze, Kling gauze, Webril followed by Coban wrap. In addition, stainless steel staples were used to reinforce the axillary surgical incision sites.
Next, the abdominal wall iliac crest regions were then prepped and draped in the usual sterile manner. Next, lidocaine 1% with epinephrine 1:100,000 mixed equally with 0.25% Marcaine 1:200,000 was used to infiltrate around the region of the umbilicus as well as the surgical incisions. Next, 5 mm incisions in the planned surgical incision sites were then used for infiltration of approximately 1 liter of superwet solution. After allowing for adequate vasoconstriction, lipoplasty was also undertaken in the abdominal wall and iliac crest regions, and using 3 and 4 mm round 3-hole blunt cannulas and 4 mm flat tubal cannula, lipoplasty was undertaken. Approximately 800 mL of supernatant fat was removed.
Next, the circumumbilical incision was then carried out followed by the transverse lower abdominal wall incision. Next, subcutaneous flaps were then elevated. Following completion of elevation of the subcutaneous flaps, the rectus sheath was then plicated in two layers, a central layer of running #1 PDS followed by a subsequent layer of running and locking #1 Prolene. The sutures ran from subxiphoid to supraumbilical and supraumbilical to pubic. Following completion of plication of the abdominal wall fascial laxity, the areas lateral to the incision lines were then infiltrated with a solution of 0.5% Marcaine with epinephrine 1:100,000. Approximately 60 mL was utilized.
Next, the patient was placed in approximately 45 degrees of flexion, and utilizing the Lockwood skin demarcator, the areas of skin resection were demarcated. Next, the central portion of the excised skin was undertaken and temporarily approximated with stainless steel staples. This was then continued with the use of the Lockwood clamp to determine the areas of extent of skin resection, both to the right of the femoral triangle and to the left of the femoral triangle until the posterior iliac crest region was reached.
Next, the patient was placed in nearly supine position on the operating room table and the location of the umbilicus was demarcated. Next, an umbilicoplasty in 3 layers was then taken utilizing 2-0 PDS undyed and 3-0 Monocryl undyed. Next, several stainless steel staples were removed centrally. The abdominal wall was then irrigated with copious amounts of triple antibiotic normal saline solution. Hemostasis was observed.
Next, three 10 mm Jackson-Pratt drains were placed; one each laterally and one centrally. They were exited through the lower skin flap and sutured to the skin with 3-0 nylon and connected to wall suction.
Next, the patient was placed back in approximately 30 degrees of flexion of the back and the incisions were then closed in three layers, a deep layer with undyed 2-0 PDS for the SFS layer followed by 2-0 Monocryl for the intermediate layer, and 3-0 undyed Monocryl for the deep dermis layer followed by 3-0 subcuticular undyed Monocryl for the final layer. Xeroform gauze, 4 x 4 gauze, ABD pads were then placed over the abdominal wall incisions and the drains were then connected to closed bulb suction.
The patient tolerated the procedure well. She was extubated in the operating room and then taken to the recovery room in stable condition. She was then placed on 23-hour observation status.
