Neck CAT Scan

NECK CAT SCAN

INDICATION FOR STUDY:  Left neck mass.

FINDINGS:  Computerized axial tomography of the neck, both without and with intravenous contrast enhancement was accomplished without difficulty.

In the mid left neck, there is a reasonably well-marginated soft tissue density measuring
1.8 x 1.2 cm lying just anterior to the left sternocleidomastoid muscle.  The remaining tissue structures within the neck appear to be symmetrical bilaterally.  Vascular structures appear to be normal.

The thyroid gland appears to be bilaterally symmetrical with no solid or cystic lesions seen.

IMPRESSION:  1.8 x 1.2 cm soft tissue mass in the left mid neck lying just anterior to the edge of the left sternocleidomastoid muscle.

Abdominal and Pelvic CAT Scan

ABDOMINAL AND PELVIC CAT SCAN

INDICATION FOR STUDY:  Abdominal pain as well as scrotal pain and the patient was known scrotal varices.

FINDINGS:  Computerized axial tomography of the abdomen and pelvis, both without and with intravenous contrast enhancement and following oral contrast was accomplished without difficulty.

The lower lung fields appear to be normal.  There is fatty infiltration of the liver with decreased attenuation of the liver in relationship to the spleen.  The gallbladder is normal.  The pancreas, adrenal glands, and right kidney are normal.  A very small cyst is seen in the anterior aspect of the left kidney in its mid portion.  The spleen appears to be normal.

Vascular structures are normal.  I see no evidence of ascites.

Extending the examination into the pelvis, organ structures and tissue planes appear to be normally maintained.  No solid or cystic lesions are seen.  I see nothing to suggest diverticular disease involving the lower colon.  The upper scrotum appears to be normal.  A more definitive examination of the scrotum and is contents would be by ultrasound.

IMPRESSION:

1.                   The lower lung fields are normal.

2.                   Fatty infiltration of the liver.

3.                   Small left renal cyst.

4.                   No acute abdominal or pelvic abnormality is identified.

Abdominal CAT Scan

ABDOMINAL CAT SCAN

FINDINGS:  Computerized axial tomography of the abdomen, both without and with intravenous contrast enhancement and following oral contrast was accomplished without difficulty.

The lower lung fields appear to be normal.  The hepatic parenchyma appears to be grossly normal.  On image 8 of series 4, there is a very small area of lucency seen in the anterior aspect of the liver perhaps representing a very small hepatic cyst.  No other solid or cystic lesions are seen.

The pancreas, spleen, adrenal glands, and kidneys appear grossly normal with the exception of some small areas of decreased attenuation seen in the kidneys representing simple renal cysts.  These are quite small.  No solid masses are indicated.

Vascular structures are normal.  I see no evidence of periaortic or retroperitoneal adenopathy.  There is no evidence of ascites.

Extending the CAT scan into the pelvis, organ structures and tissue planes in the upper pelvis appear to be normal.

IMPRESSION:

1.                   Probable very small hepatic cysts seen in the anterior aspect of the liver as described.

2.                   Small bilateral renal cysts.

3.                   No acute abdominal process is identified.

Pulmonary Function Test (PFT)

PATIENT NAME:  Patient Name

DOB:  10/18/1932

DOP:  09/20/11

DOD:  10/10/11

PROCEDURE:  PFT.

FINDINGS:

The flow volume loop shows a restrictive pattern.

Spirometry shows that the forced vital capacity is 54% of predicted.  The forced expiratory volume at one second is 68% of predicted.  The forced expiratory volume at one second to the forced vital capacity ratio is 0.92.  After the administration of a bronchodilator, the forced vital capacity increased by 20% and the forced expiratory volume at one second increased by 8%.

Lung volumes were not measured.

The diffusion capacity is 50% of predicted, which corrects for alveolar volume.

IMPRESSION:

1.   Patient has a restrictive lung defect.  However, patient did have significant bronchodilator response.  Therefore, a trial of inhaled bronchodilators may be indicated.

2.   Diffusion capacity corrects for alveolar volume, which suggests an extrathoracic or extraparenchymal lung defect.  Clinical correlation is recommended.

Brain CAT Scan

BRAIN CAT SCAN

INDICATION FOR STUDY:  Syncope.

FINDINGS:  Computerized axial tomography of the brain, but without intravenous contrast enhancement was accomplished without difficulty.

I see no evidence of a recent intra-axial or extraaxial hemorrhagic process.  There is no mass effect.  The brain substance abuts the inner table of the calvarium throughout.

There is mild cerebral atrophy seen.

IMPRESSION:

1.                   Mild cerebral atrophy.

2.                   No acute intracranial process is identified.

CT Evaluation of the Soft Tissues of the Neck without Contrast

CT EVALUATION OF THE SOFT TISSUES OF THE NECK WITHOUT CONTRAST

INDICATION FOR STUDY:         Palpable mass, left-sided neck.  Thyroid ultrasound examination from February 20, 2012.

FINDINGS:             The area of concern was marked with a metallic BB.  There is no significant mass lesions or adenopathy clearly identified.  There are vessels identified, which of course are in a normal pattern.  The muscles, submandibular gland, parotid gland, and thyroid gland show no significant abnormality.  The examination is limited without I.V. contrast, but there is no specific change to suggest abnormal mass lesion or adenopathy.  There are a few small nonspecific lymph nodes, which appear within normal limits and symmetric in appearance.  The visualized airway shows no gross abnormality.  The parapharyngeal fat and prevertebral soft tissues show no significant abnormality.

IMPRESSION:        The area of concern in the left neck was marked and there is no specific lesion or mass clearly identified.  The soft tissues and muscle planes all appear symmetric on the left and right side.  There are degenerative changes of the spine, but no other significant abnormality identified.  The examination is limited without I.V. contrast, but from the evaluation, there is no specific lesion or mass.  Would recommend clinical correlation or further evaluation as necessary.

CT Evaluation of the Abdomen and Pelvis with and without I.V. Contrast

CT EVALUATION OF THE ABDOMEN AND PELVIS WITH AND WITHOUT I.V. CONTRAST

INDICATION FOR STUDY:         Fall.  Fractured ninth left rib.

FINDINGS:             I understand the patient has a left ninth rib fracture, which is nondisplaced and not as apparent on the CT evaluation, but it is identified on approximately image 6 of series 3.  There is no significant surrounding edema.  The remainder of the bony structures show slight chronic changes, but no other acute abnormality in the abdomen or pelvis.  In the liver, there are a few simple cysts identified, one noted in the left lobe on image 12 through 14 of series 5, which measures approximately 2 cm.  There is another one in the right lobe measuring 4 mm on image 14, another one in the right lobe more posteriorly and medially measuring 14 mm on image 17, and another one in the right lobe more laterally and inferiorly measuring 14 mm on image 22.  There is a simple cyst in the left kidney, which measures approximately 14 mm on image 27.  It is not as optimally characterized.  There is a horseshoe kidney.  There is no evidence of significant fracture or laceration to the liver, spleen, or kidneys.  There is no evidence of free fluid or free air in the abdomen or pelvis.  There is no evidence of calculi in the kidneys or gallstones.  There is no obstruction.  The remainder of the abdomen and pelvis shows no gross abnormality.  The pelvic evaluation shows no significant free fluid or free air and the bony structures show no fracture.  There is contrast in the bladder and the bladder is not significantly distended.  The bowel loops are not completely opacified.  A preliminary report was discussed with Dr. Roberts.

IMPRESSION:        Horseshoe kidney.  Simple cyst in the left kidney measuring approximately 1.4 cm.  Multiple simple cysts in the liver.  No clear evidence of significant laceration or rupture of the solid organs in the abdomen or pelvis.  The patient’s known left ninth rib fracture is identified on the CT evaluation as discussed above.  There is no free fluid or free air.  Would recommend clinical correlation or further evaluation as needed.

Radiofrequency Rhizotomy

Radiofrequency Rhizotomy

Diagnosis:  ___________________

The patient presents today for radio frequency rhizotomy of the medial branch nerves of the cervical facet joints at the C4-C5, C5-C6, and C6-C7 levels on the right/left side.

Procedure:  The patient/family member has been informed of the risks and benefits of the planned procedure.  Procedure – radiofrequency rhizotomy of the medial branch nerves of the cervical facet joints at the C4-C5, C5-C6, and C6-C7  levels on the  right/left side

Informed consent was obtained.  In the fluoroscopy room, the patient was placed in a prone position and pillows are placed under the chest to allow the cervical spine to be moderately flexed without discomfort.  The patient’s forehead was allowed to rest on a folded blanket on a small pillow.  An AP view of the cervical spine was obtained.  The fluoroscopy beam was rotated to view the center of the neural arch.  The target level was then identified.  The skin was prepped and draped in a sterile manner.  Under fluoroscopic the skin and deeper tissues were numbed with 0.5% lidocaine.  Under fluoroscopic guidance a 2-inch, 20 gauge radiofrequency probe was guided to contact the centroid of the neural arch.  The needle position was confirmed on AP and lateral views.  Initially sensory stimulation was done, and then motor stimulation was done.  Contractions of the multifida were noted.  No extremity contractions noted.  The impedance at each of the levels was noted to be  right/left at the C4-C5 level,  right/left at the C5-C6 level,  right/left at the C6-C7 level.  Then using the radiofrequency rhizotomy technique, the medial branch nerves at each of these levels was lesioned.  The duration of the lesioning was 120 seconds and the temperature was maintained at 42 degrees.  The patient tolerated the procedure well.  Complications none.

Caudal Epidural Steroid Injection

Procedure Note – Caudal Epidural Steroid Injection

PATIENT:  ____________________

PHYSICIAN:  Physician Name

DIAGNOSIS:  _______________

DATE OF PROCEDURE:  ____________

PROCEDURE:  Caudal Epidural

The patient/family member has been informed of the risks and the benefits of the planned procedure.

In the fluoroscopy room the patient was placed in a prone position and the skin over the lumbosacral spine including the gluteal cleft was prepped and draped in a sterile manner.  The sacral curve was identified under fluoroscopy.  The sacral cornu was identified by palpation.  The skin and deeper tissues were numbed with 0.5% lidocaine.  The caudal epidural space was accessed with a 22 G 3½ inch spinal needle via the sacral cornu.  Loss of resistance was obtained.  2 cc of Omnipaque was injected.  The dye was seen to spread along the sacral epidural space.  Then 18 cc of 1/8 bupivacaine and 80 mg of methylprednisolone was injected.

Patient tolerated the procedure very well.

Complications:  None.

Full discharge instructions were given to the patient.  The patient was discharged in a stable condition.

__________

Physician Name

EXCISION OF LIPOMA

EXCISION OF LIPOMA

PREOPERATIVE DIAGNOSIS:  Lipoma.

POSTOPERATIVE DIAGNOSIS:  Lipoma.

PROCEDURE PERFORMED:  Excision of lipoma.

ANESTHESIA:  Local anesthesia.

COMPLICATIONS:  None.

INDICATIONS:  I recommended to the patient to undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with the patient, and the patient was agreeable to surgery.

DESCRIPTION OF PROCEDURE:  The patient was identified and an informed consent was obtained.  A marking pen was used to draw an outline of the lipoma and a planned skin excision on the skin surface.  The outline of the tumor helped to delineate margins, which was obscured after administration of the anesthetic.  Excision of some skin helped to eliminate redundancy at closure.  The skin was then cleansed with povidone iodine/chlorhexidine solution, making sure to avoid wiping away the skin markings.  The area was draped with sterile towels.  Local anesthesia was administered with 1/2 percent lidocaine with epinephrine, as a field block.  A 3-mm to 4-mm incision was made over the lipoma.  The incisions were configured like a fusiform excision following the skin tension lines and were smaller than the underlying tumor.  The central island of skin to be excised was grasped with a hemostat/Allis clamp, which was used to provide traction for the removal of the tumor.  Dissection was then performed beneath the subcutaneous fat to the tumor.  Tissue cutting was performed under direct visualization using a #15 scalpel/scissors around the lipoma.  Care was taken to avoid nerves/blood vessels that may lie just beneath the tumor.  Once a portion of lipoma has been dissected from the surrounding tissue, hemostats/clamps were attached to the tumor to provide traction for removal of the remainder of the growth.  Once it was freed, the lipoma was delivered as a whole.  The surrounding tissue in the hole was palpated to ensure complete removal of the tumor.  Adequate hemostasis was achieved following the removal of the lipoma using hemostats/suture ligation.  The dead space was closed beneath the skin using buried, interrupted 3-0/4-0 Vicryl sutures.  Occasionally drains have been placed to prevent fluid accumulation.  The skin was then closed with interrupted 4-0/5-0 nylon sutures.  A pressure dressing was placed to reduce the incidence of hematoma formation.  The patient is given routine wound care instructions, and the wound is checked in two to seven days.  The sutures are removed after seven to 21 days, depending on the body location.  Specimens were submitted for histologic analysis.

Lumbar Epidural Injection

Lumbar Epidural Injection Procedure

PATIENT:  ____________________

PHYSICIAN: 

DIAGNOSIS:  Lumbar Radiculopathy

DATE OF PROCEDURE:  ____________

PROCEDURE:  Lumbar Epidural Injection

The patient/family member has been informed of the risks and the benefits of the planned procedure.

In the fluoroscopy room the patient was placed in a prone position and the skin over the lumbosacral spine was prepped and draped in a sterile manner.  The skin and deeper tissues were numbed with 1% lidocaine.  Using a translaminar approach at the ________ level, a 3½ inch 20 gauge Touhy needle was advanced under fluoroscopic guidance, using the loss of resistance technique into the epidural space.  Needle position was conformed on AP and lateral views.  Aspiration was negative for CSF and blood.  10 cc of a mixture of _________ and 80 mg of methylprednisolone was injected into the epidural space.

Patient tolerated the procedure very well.

Complications:  None.

Full discharge instructions were given to the patient.  The patient was discharged in a stable condition.

Hip Joint Injection

Hip Joint Injection

Procedure:  Hip Injection

Procedure in Detail:  The patient/family member has been informed of the risks and benefits of the planned procedure.  Informed consent was obtained.

In the fluoroscopy room, the patient was placed in a prone position and the skin over the left/right hip was prepped and draped in a sterile manner.  The hip joint was identified on fluoroscopy.  The skin and deeper tissues were numbed with 0.5% lidocaine.  Under fluoroscopic guidance a 3½ inch, 22 gauge spinal needle was advanced into the cavity of the hip joint.  The joint was injected with a mixture of 4 cc each of 1/8th Marcaine and 40 mg each of methylprednisolone.

The patient tolerated the procedure well.  The patient’s vital signs were monitored during the procedure.

Complications:

None.  Vital signs are stable during and after the procedure.

Full discharge instructions were given to the patient.  Patient was discharged in a stable condition.

Follow up:

I shall follow up in six weeks time to evaluate the progress.

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Liposuction Procedure

Liposuction

Preoperative diagnoses:

1.      Deformity, right breast reconstruction.

2.      Excess soft tissue, anterior abdomen and flank.

3.      Lipodystrophy of the abdomen.

Postoperative diagnoses:

1.      Deformity, right breast reconstruction.

2.      Excess soft tissue, anterior abdomen and flank.

3.      Lipodystrophy of the abdomen.

Procedures Performed:

1.      Revision, right breast reconstruction.

2.      Excision, soft tissue fullness of the lateral abdomen and flank.

3.      Liposuction of the supraumbilical abdomen.

Anesthesia: General.

Indications:  The patient is a 41-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction.  The patient now had lateralization of the implant with loss of medial fullness for correction.  It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length.  The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected.  She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such.  The above-noted procedure was discussed with the patient in detail.  The risks, benefits and potential complications were discussed.  The patient was marked in the upright position and then taken to the operating room for the above-noted procedure.

Procedure in Detail:  The patient was taken to the operating room and placed in the supine position.  Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion.  The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear.  At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached.  This was then opened.  The implant was removed and placed on the back table in antibiotic solution.  Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast.  The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form.  The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant.  The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness.  With this completed, the implant was again removed, antibiotic irrigation was performed.  A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed.  The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures.  The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture.  Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours.  This was closed with 6-0 Prolene suture.  The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus.  A Kerlix dressing and a surgical bra was placed to the chest area.  A compressive garment was placed.  The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition.  Sponge, needle, lap, instrument counts were all correct.  The patient tolerated the procedure well.  There were no complications.  The estimated blood loss was approximately 25 mL.

Lumbar Spine X-ray, AP and Lateral Views

X-RAY EVALUATION OF THE LUMBAR SPINE, AP AND LATERAL VIEWS

INDICATION FOR STUDY:         Lumbar fusion.  Follow-up.  Prior examination from November 22, 2010.

FINDINGS:               There is continued evidence of postsurgical changes with transfixing plate and screws from L2 through S1.  There are prior laminectomy changes.  The metallic hardware appears in good position and without gross abnormality.  There is no significant new area of acute abnormality.  There is continued evidence of slight chronic changes and osteopenia of the bones.  If there is any further concern, would recommend further evaluation as needed.

X-Ray of the Cervical Spine

X-RAY EVALUATION OF THE CERVICAL SPINE

FINDINGS:  Views of the cervical spine shows loss of the usual cervical lordosis.  The vertebral body heights and disc spaces appear normally maintained and oblique films fail to demonstrate any significant encroachment upon the neuroforamina, though there may be some posterior osteophyte formation seen at C5-C6 and a cervical MRI may be of further diagnostic value in better defining this questioned defect.

Flexion and extension views show no evidence of subluxation.  The retropharyngeal and retrotracheal air space appears to be normal and soft tissues are otherwise normal.

IMPRESSION:

1.          Loss of the usual cervical lordosis consistent with muscle spasm.

2.     Questioned osteophyte encroachment upon the neuroforamina at C5-C6 and a cervical MRI is recommended for further evaluation.

Chest X-Ray, Two Views

Chest X-Ray, Two Views

FINDINGS:  There is evidence of prior surgery with sternal wires.  The cardiac silhouette appears slightly enlarged.  There is pulmonary vascular prominence, which appears chronic in nature and would recommend clinical correlation.  The possibility of mild congestive heart failure cannot be excluded.  There is no evidence of significant pleural effusions, pneumothorax, or infiltrates.  There is osteopenia of the bones and degenerative changes.

IMPRESSION:  Slight pulmonary vascular prominence, which may be chronic in nature versus mild congestive heart failure.  Prior surgery and mild cardiomegaly.  Would recommend further evaluation as needed.  There are slight atherosclerotic changes to the aorta, which are calcified.

Shoulder Joint Injection

Shoulder joint injection

Procedure in Detail:  The patient/family member has been informed of the risks and benefits of the planned procedure.  Informed consent was obtained.

In the fluoroscopy room, the patient was placed in a supine position and the skin over the right shoulder was prepped and draped in a sterile manner.  The joint  was identified on fluoroscopy.  Under fluoroscopic guidance the skin and deeper tissues were numbed  with 0.5% lidocaine.  Under fluoroscopic guidance, a 3½ inch 22 gauge spinal needle was advanced into the cavity of the shoulder joint.  The joint  was injected with a mixture of 4 cc each of 1/8th bupivacaine and 40 mg each of methylprednisolone .

The patient tolerated the procedure well.  The patient’s vital signs were monitored during the procedure.

Heel Pain Injection

Heel Pain Injection

Procedure Technique:  Informed consent was obtained from the patient.  Special mention was made of the possibility of infection and necrosis of the heel pad.  The patient was placed in the supine position.  The painful area in the medial aspect of the heel was identified by palpation.  After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle.  The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus.  The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly.  The contents of the syringe were then gently injected.  Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site.  Subsequently the needle was removed.  Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.  The patient tolerated the procedure well.

Knee Joint Injection

Knee Joint Injection

Diagnosis: 

Date of Procedure: 

The patient presents today for a right/left knee joint injection today.

Procedure in Detail:  The patient/family member has been informed of the risks and benefits of the planned procedure.  Procedure is right/left knee joint injection.  Informed consent was obtained.

In the fluoroscopy room, the patient was placed in a supine position and the skin over the right/left knee was prepped and draped in a sterile manner.  The knee joint was identified on fluoroscopy.  The skin and deeper tissues were numbed with 0.5% lidocaine.  Under fluoroscopic guidance, a 3.5-inch, 20 gauge spinal needle was advanced into the cavity of the knee joint.  The joint was injected with a mixture of 4 cc each of 1/8th Marcaine and 40 mg each of methylprednisolone.  The patient tolerated the procedure well.  Complications none.

Flap Revision

Flap Revision

Preoperative Diagnoses:

1.      Bilateral breast asymmetry.

2.      Right breast macromastia.

3.      Right abdominal scar deformity.

4.      Left abdominal scar deformity.

5.      Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.

6.      A 2.3 cm lesion right inferior breast.

7.      Lesion measuring 1.0 cm right inferior breast lateral.

Postoperative Diagnoses:

1.      Bilateral breast asymmetry.

2.      Right breast macromastia.

3.      Right abdominal scar deformity.

4.      Left abdominal scar deformity.

5.      Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.

6.      A 2.3 cm lesion right inferior breast.

7.      Lesion measuring 1.0 cm right inferior breast lateral.

Procedures:

1.      Right breast flap revision.

2.      Left breast flap revision.

3.      Right nipple reconstruction.

4.      Right breast reduction mammoplasty.

5.      Right abdominal scar deformity.

6.      Left abdominal scar deformity.

7.      Excision of right breast lateral lesion enclosure.

8.      Excision of right breast medial lesion enclosure.

Anesthesia:  General.

Complications:  None.

Drains:  None.

Specimens:  Right breast skin and lesions x3.

Indications:  This patient is a 45-year-old white female who presents for a revision of previous bilateral breast reconstruction.  The patient had asymmetry as well as left breast hypertrophy, and therefore, the above-mentioned procedures were indicated.  The patient was informed about the possible risks and complications of the above-mentioned procedures and gave an informed consent.

Procedure:  The patient was brought to the operating room and placed supine on the operative table.  After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the abdomen and chest were prepped and draped in a standard surgical fashion.

First, attention was turned to the left breast where the liposuction was performed laterally to allow for better contour and minimize the outer quadrant.  The incision was made for this and was then closed with 3-0 Prolene interrupted suture.

Then, attention was turned to the right breast where the liposuction was also performed to reduce the medial superior and lateral quadrants.  Once this was performed, the vertical reduction mammoplasty was outlined.  Prior to that, the nipple reconstruction was performed with a keyhole pattern flap.  The flap was elevated with 16-blade and hemostasis was then obtained with the Bovie.  The flap was then sutured onto itself and secured with 3-0 Prolene interrupted sutures.  Then the lateral and medial limbs were undermined to close the defect and this was performed with 6-0 Monocryl interrupted sutures.  Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology.

Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions.  Once this was done, a 6-0 Monocryl interrupted sutures were used to close the inferior limb.  Subsequently 4-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex.  Once this was done, the remaining incision was then closed with 6-0 Monocryl followed by 2-0 Monocryl subcuticular sutures.  Subsequently, the two lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology.  They were closed in 2 layers using 6-0 Monocryl followed by 2-0 Monocryl subcuticular suture.

Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required.  Subsequently, the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 7 x 2 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 6-0 Monocryl followed by 2-0 Monocryl subcuticular suture.

Attention was then turned to the contralateral left side where there was a larger defect.  There was a larger excision required measuring approximately 14 x 2 cm.  The superior and inferior edges of skin were undermined and closed primarily using 6-0 Monocryl followed by 2-0 Monocryl subcuticular sutures.  Steri-Strips were placed on all incisions followed by surgical bra.

The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition.  All instruments, needle counts, and sponges were correct at the end of the case.