Results
PLASTIC SURGERY REPORT (Order 114290245)
Result Information Exam Date
Status Final result
Result Date 2/5/2016
Lab and Collection PLASTIC SURGERY REPORT (Order#114290245) on 2/5116 - Lab and Collection Information Transcription
ID SOFTMED1982457
Date
Author
PLASTIC SURGERY REPORT
NAME:
HOSPITAL#:
PHYSICIAN:
BILLING#:
PAT. TYPE:
0
PATIENT LOC DISCH DATE:
ADMIT DATE:
PREOPERATIVE DIAGNOSES: Personal history of breast cancer, bilateral acquired absence of the breast, lipoma of the posterior neck. POSTOPERATIVE DIAGNOSES: Personal history of breast cancer, bilateral acquired absence of the breast, lipoma of the posterior neck. PROCEDURE: 1. Left breast revision with fat grafting and subdermal scar release. 2. Fat grafting to the right breast. 3. Excision 3 cm deep lipoma of the posterior neqk. SURGEON: ASSISTANT: ANESTHESIA:
MAC/monitored anesthesia care.
INDICATION FOR OPERATION: The patient is a 47-year-old woman who has previously undergone bilateral mastectomies, bilateral expander implant reconstruction. She has a lipoma on the back of her neck which is irritating to her and causing her discomfor-t. Also, she has some irregularities and asymmetries in the breast that can be improved with revision and fat grafting. I believe she understands the risks' and benefits, the multi-step nature of .the process· and agrees to proceed. DESCRIPTION OF PROCEDURE: After being marked in the upright position, she is taken to the operating room where she is sterilely prepped and draped · with ChloraPrep in standard manner, local anesthesia· was infiltrated. . She. is in the right lateral decubitus position with the right side down, left side up. A 3 .,5 cm incision is made transversely directly over the lipoma. Subcutaneo. us fat is incised, and then a spiculated multilobulated lipoma is found just above the extensor muscle fascia. This liporna was removed. from the fascia. It was removed in several pieces. It is sent for routine
The incision is closed with layers of 3-0 Monocryl .
pathology,
. She is then placed into a supine position where she was sterilely prepped and draped again, Fat is harvested from the abdomen with a 3.0 mm Merc�das tip cannula into a Revolv$ £at catchment system. An 18 gauge needle is used to lift and release subdermal scarring on the left breast in 4 separate locations. After this is done, approximately 50 mL of fat is injected across the left breast, Next, an additional 50 mL of fat is injected across the right breast. All this is done with a Coleman style injection cannula. Steri-Strips and sterile dressings are then applied. ESTIMATED BLOOD LOSS:
Minimal.
Sponge and instrument counts were correct. There were no complications .. The patient tolerated procedure well, was taken to recovery area in good condition.
/mrc
D:
02/05/2016
12:23 P
T:
02/05/2016 03:21 P
Unreviewed
Dictated by: cc:
Display only: Transcription (SOFTMED1982457) on 2/5/2016 by
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Order
Order Information
PLASTIC SURGERY REPORT [400818] (Order 114290245) Ordered By Nmh Incoming Transcription Interface
Order Providers
Quantity Ordering Quantity 1 Llnl<ed Charges . · No charges linked to this procedure
Ord Status Normal