Cosmetic Surgery Operative Medical Note Sample Format #1
PREOPERATIVE DIAGNOSIS: Micromastia.
POSTOPERATIVE DIAGNOSIS: Micromastia.
PROCEDURE PERFORMED: Augmentation mammoplasty in a subpectoral plane.
SURGEON: John Doe, MD
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old female who wishes to have larger breasts. She fully understands the potential complications of infection, bleeding, scarring, asymmetry, capsular contracture, deflation, and diminished or loss of nipple sensation.
OPERATIVE PROCEDURE: After informed consent, the patient was taken to the operating room. General endotracheal anesthesia was performed without difficulty. Antithrombotic devices were put on both lower extremities. and her entire breasts and upper abdomen was prepped and draped in a sterile fashion.
An inframammary incision was made bilaterally with a 10 blade. Pectoralis muscle was raised up off of the rib cage. Dissection was carried up to the second rib superiorly, medially to the sternum, inferiorly to the inframammary fold, laterally to the anterior axillary line. The pectoralis muscle fibers were released inferiorly to the pectoralis fascia. The pocket was thoroughly irrigated with antibiotic solution.
Meticulous hemostasis was obtained with Bovie cautery and a 600 mL implant was placed on the left and it was filled to 600 and on the right it was filled to 650. The patient was placed in a sitting position. Pockets were adjusted.
Good symmetry was noted, and the patient was closed in layers with 3-0 Vicryl in the deep and a 4-0 Monocryl subcuticular. Bandages were applied. The patient tolerated the procedure well and left the operating room extubated in good condition.
Cosmetic Surgery Operative Medical Note Sample Format #2
PREOPERATIVE DIAGNOSIS: Macromastia.
POSTOPERATIVE DIAGNOSIS: Macromastia.
PROCEDURE PERFORMED: Bilateral breast reduction.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who wishes to essentially undergo sex transformation. She wishes today to have both breasts reduced in size. The potential complications were fully explained to her such as infection, bleeding, scarring, numbness, loss of nipple sensation, loss of the free nipple grafts, asymmetry, and the need for more surgery.
DETAILS OF PROCEDURE: After informed consent, the patient was first marked in the office. The patient was then taken back to the operating room where general endotracheal anesthesia was performed without difficulty. Antithrombotic devices were put on both lower extremities. Her entire breasts were prepped and draped in a sterile fashion.
A large ellipse was drawn in the office, first the nipple was marked and then using a 10 blade, the nipple was then removed off of both breasts. Following this, both large ellipses were incised with a 10 blade. Further dissection with Bovie cautery was carried down to the pectoralis fascia. The breast tissue and fat were removed off of the pec, leaving enough tissue to keep the shape. Hemostasis was obtained with Bovie cautery.
Irrigation was performed with antibiotic solution. The incision lines were closed in layers using 3-0 Vicryl in the deep and 4-0 Monocryl subcuticular. A small circle was made on the skin and this was de-epithelialized and the nipple graft was sewn down with 5-0 chromic and bolstered with 3-0 silk, Xeroform, and cotton balls. Then, 4 x 4s were applied and an Ace bandage. Also note, two #19 Blake drains were placed through separate stab wounds and secured with 2-0 silk. Complications none. Estimated blood loss less than 75 mL.
Cosmetic Surgery Operative Medical Note Sample Format #3
PREOPERATIVE DIAGNOSIS: Lipodystrophy of the neck.
POSTOPERATIVE DIAGNOSIS: Lipodystrophy of the neck.
PROCEDURE PERFORMED: Liposuction of the neck.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old female who presents with submental fat and wishes to have it removed. The potential complications were fully explained to her such as infection, bleeding, depression, scarring, facial nerve damage. She fully understands and wishes to go ahead.
DETAILS OF PROCEDURE: After informed consent, the patient was taken to the operating room. General endotracheal anesthesia was performed without difficulty. Her entire lower face and neck were prepped and draped in a sterile fashion. Following this, an injection of LR mixed with epinephrine 1:1,000,000 was injected into her submental area and below her jaw line of the neck. A total of 60 mL was used. Liposuction was then performed with a 3-mm cannula and approximately 20 mL of fat was removed. The stab wounds were then closed with 6-0 nylon and a compressive dressing was placed. The patient tolerated the procedure well and left the operating room extubated and in good condition.
Cosmetic Surgery Operative Medical Note Sample Format #4
PREOPERATIVE DIAGNOSIS: Large nasal hump with long nasal tip and wide nasal bone.
POSTOPERATIVE DIAGNOSIS: Large nasal hump with long nasal tip and wide nasal bone.
PROCEDURE PERFORMED: Rhinoplasty.
SURGEON: John Doe, MD
DETAILS OF PROCEDURE: After informed consent, the patient was taken to the operating room. General endotracheal anesthesia was performed without difficulty. Antithrombotic devices were put on both lower extremities, and her entire face was prepped and draped in a sterile fashion. Her nasal hairs were trimmed and her inner nose was also prepped with Betadine solution.
An incision was made at the narrow portion of her columella. The incision followed inward into the nasal mucosa and then followed into a marginal incision. The nasal skin was elevated up off the cartilage where a good exposure of the lower lateral and upper lateral cartilages was noted. Using a Freer elevator, the skin was elevated up off the nasal dorsum and nasal bones. At this point, the lower lateral cartilage was taken down leaving 4-mm of lower lateral cartilages both sides. Using an osteotome, the nasal bone was taken down, and using a 15 blade, the cartilaginous portion of the septum was also sharply shaved down as well to give her a nice straight dorsum.
At this point, neat osteotomies were done low to high. The skin was placed back over her nose and it appeared that she had a nice result. Her nasal hump was taken down and her tip looked good. The incision line was closed using 6-0 nylon in the skin and 4-0 chromics in the nasal mucosa. Steri-Strips were applied and then a nasal splint. The patient tolerated the procedure well and left the operating room in good condition.
Cosmetic Surgery Operative Medical Note Sample Format #5
PREOPERATIVE DIAGNOSES:
1. Stage III ptosis of the breast bilaterally.
2. Radix of the face.
POSTOPERATIVE DIAGNOSES:
1. Stage III ptosis of the breast bilaterally.
2. Radix of the face.
PROCEDURES PERFORMED:
1. Bilateral mastopexies.
2. Remove and replacement of both implants.
3. 35% TCA peel to the face.
4. Botox injection into the forehead and crow’s feet.
5. Fat injection to the nasolabial fold.
SURGEON: John Doe, MD
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old female who presents with stage III ptosis of both breasts. She has prior saline implants in but her breast skin fold off the implants. She also has radix of the face and is to undergo a TCA peel. She also wishes to have Botox injected into her forehead and flatten her nasolabial fold. The potential complications were explained, including infection, bleeding, scarring, diminished or loss of nipple sensation, separation of the incision line, deflation of the implant, capsular contracture, and asymmetry as far as the peel on the face goes. She fully understands the potential complication of scarring, pigmentary changes, asymmetry for the fat injection into the nasolabial fold, loss of the fat, and the need for more surgery.
DETAILS OF PROCEDURE: After informed consent, the patient was taken to the operating room. Prior to this, she was first marked in the holding area and then taken to the operating room, where general endotracheal anesthesia was performed without difficulty. Antithrombotic devices were put on both lower extremities. A Foley catheter was placed, and her entire breast and upper abdomen was prepped and draped in a sterile fashion.
A 45-mm cookie cutter was used to make impression on both areolae. A 10-blade was used to make an incision around the impression from the cookie cutter and the excess areolar tissue was then de-epithelialized. A tailor-tack mastopexy was drawn on her breast. The excess skin was excised. The dissection was carried down with the Bovie cautery to her capsule of her implants.
The capsule was entered, and her old implants removed bilaterally. Then, 400 mL high-profile implants were placed and filled to 400 mL. The patient was placed in a sitting position and additional excess skin was removed from both breasts in order to gain symmetry. The incision lines were then closed in layers using 3-0 Vicryl in the deep and 4-0 Monocryl subcuticular.
A 35-mm cookie cutter was used to make an impression in the skin. This area was then de-epithelialized and the nipple areola was then brought up and sewn to her breast skin using 3-0 Vicryl in the deep and 4-0 Monocryl subcuticular. Following this, Dermabond was applied to the incision lines.
Attention was then paid to harvesting fat in the upper abdomen. A puncture wound with a 15 blade was made. Using the Tulip system, the fat was harvested and then filled a 5 mL syringe with her fat that was first washed with sterile saline. The fat was then injected in both nasolabial folds. Following this, Botox was injected into the forehead and the crow’s feet, and a 35% TCA peel was applied to the face. Bacitracin ointment was placed over the skin on her face and 4 x 4’s on her breast with an Ace wrap. The patient tolerated the procedure well and left the operating room extubated and in good condition.
