Sample Name: Rhytidectomy & Blepharoplasty
Description: Cervical facial rhytidectomy. Quadrilateral blepharoplasty. Autologous fat injection to the upper lip - donor site, abdomen.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Ageing face.
POSTOPERATIVE DIAGNOSIS: Ageing face.
1. Cervical facial rhytidectomy.
2. Quadrilateral blepharoplasty.
3. Autologous fat injection to the upper lip.
2. Quadrilateral blepharoplasty.
3. Autologous fat injection to the upper lip - donor site, abdomen.
INDICATION: This is a 62-year-old female for the above-planned procedure. She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.
PROCEDURE: The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table. Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. This included the neck accordingly.
Two platysmal sling application and operating headlight were utilized. Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.
After completion of this portion of the procedure, the lag lid was again placed in the eyes. Eye mass was likewise clamped. Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. The right face was first operated. It was injected with a 0.25% Marcaine 1:200,000 adrenaline. A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. She had minimal subcutaneous extra fat as noted. Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. The flap was elevated without difficulty with various facelift scissors. Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.
The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.
Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication. The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene. The skin was draped appropriately and appropriate tissue was resected. A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon. The hairline temporal incision was closed with running 5-0 nylon. The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.
The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.
The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.
The patient will be admitted for overnight short stay through the cosmetic package procedure. She will be discharged in the morning.
Estimated blood loss was less than 75 cc. No complications noted, and the patient tolerated the procedure well.
Keywords: ophthalmology, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,