Hi list! I am still fairly new to Surgeries and need some guidance on this report please 
TIA
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Hidradenitis with nonhealing wound of the sternum, bilateral IMF and left axilla.
Macromastia with associated back pain, neck pain, shoulder pain and shoulder grooving.
POSTOPERATIVE DIAGNOSIS:
Hidradenitis with nonhealing wound of the sternum, bilateral IMF and left axilla.
Macromastia with associated back pain, neck pain, shoulder pain and shoulder grooving.
PROCEDURE:
Bilateral reduction mammoplasty.
Placement of matristem in bilateral breasts and in the left axilla.
DATE: 12/11/2014
OPERATIVE FINDINGS:
Bilateral macromastia with left breast greater than right breast.
SPECIMENS:
Right breast tissue 918.8 g,
left breast tissue 903.5 g.
FLUIDS:
1800 mL.
ESTIMATED BLOOD LOSS:
100 mL.
DRAINS:
None.
DISPOSITION:
Stable.
ANESTHESIA:
General LMA.
ANESTHESIOLOGIST:
ANTIBIOTIC:
Cleocin 900gm IV within one hour of incision time.
SUMMARY:
The patient was transferred to the operating room and placed into a supine position. After a time-out procedure was performed, general LMA anesthesia was induced. The patient was then prepped and draped. A formal time-out procedure was then performed. Using the preoperatively placed marks, the right breast was addressed first. The infracentral pedicle was first deepithelialized. The excess medial and lateral breast tissue was excised, with care to remove all external open wounds. The infracentral pedicle was then freed from its superior breast flap. The superior breast flap was then raised from the chest wall to the level of the clavicle. The medial, lateral and central breast flaps were then thinned to the appropriate size. The medial and lateral skin flaps were then tailored to the appropriate size. The wound was then irrigated with antibiotic-containing solution. Meticulous hemostasis was then achieved. 800gm of powdered matristem was applied the wound edges and regions of active hidradenitis excision. The wounds were then closed in layers, beginning with interrupted deep 3-0 Biosyn, followed by interrupted deep dermal 3-0 Biosyn.
The left breast was then addressed. Again, using the preoperatively placed marks, the infracentral pedicle was deepithelialized. The excess medial and lateral breast tissue was excised, with care to remove all external open wounds. . The infracentral pedicle was then freed from its superior breast attachments and the superior breast flap was elevated from the chest wall to the level of the clavicle. Again, the excess tissue from the superior, medial and lateral breast flaps were thinned. The medial and lateral skin flaps were tailored to the appropriate size. Care was taken to ensure symmetry at this point. After symmetry was noted, the wound was again irrigated with antibiotic-containing solution and meticulous hemostasis was achieved. 800gm of powdered matristem was applied the wound edges and regions of active hidradenitis excision. The wound was then closed using interrupted deep 3-0 Biosyn, followed by interrupted deep dermal 3-0 Biosyn.
Nipple position was then marked, noting a position 6 cm from the inframammary crease and 9.5 cm from the marked midline. The patient was placed into a sitting position where nipple symmetry was noted, as was breast size and shape. The patient was placed back into a supine position, where the incisions were made sharply full thickness. The subcutaneous tissue was divided with electrocautery. The nipples were then delivered through the incision, 100gm of powdered matristem was applied to the wound edges and the nipple inset using interrupted deep dermal 3-0 Biosyn. All incisions were then closed with a running 4-0 Biosyn subcuticular stitch. Benzoin followed by Steri-Strips were applied to the incisions.
The left axilla wound was inspected and noted to be under tension, therefore excision of this tissue was not able to be done. 200gm of powdered matristem was applied to the open wound followed by a single layer 3x3.5 cm matristem wound matrix. Adaptic and surgilube was then applied and a bolster dressing was secured with 4-0 nylon. The patient was placed into dressings consisting of dressing sponges, followed by circumferentially placed Kerlix and Ace wraps. The patient was allowed to awaken from anesthesia. The LMA device was removed and she was transferred to the postanesthetic care unit in stable condition. The patient tolerated the procedure well without complications. Counts were correct
TIA
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Hidradenitis with nonhealing wound of the sternum, bilateral IMF and left axilla.
Macromastia with associated back pain, neck pain, shoulder pain and shoulder grooving.
POSTOPERATIVE DIAGNOSIS:
Hidradenitis with nonhealing wound of the sternum, bilateral IMF and left axilla.
Macromastia with associated back pain, neck pain, shoulder pain and shoulder grooving.
PROCEDURE:
Bilateral reduction mammoplasty.
Placement of matristem in bilateral breasts and in the left axilla.
DATE: 12/11/2014
OPERATIVE FINDINGS:
Bilateral macromastia with left breast greater than right breast.
SPECIMENS:
Right breast tissue 918.8 g,
left breast tissue 903.5 g.
FLUIDS:
1800 mL.
ESTIMATED BLOOD LOSS:
100 mL.
DRAINS:
None.
DISPOSITION:
Stable.
ANESTHESIA:
General LMA.
ANESTHESIOLOGIST:
ANTIBIOTIC:
Cleocin 900gm IV within one hour of incision time.
SUMMARY:
The patient was transferred to the operating room and placed into a supine position. After a time-out procedure was performed, general LMA anesthesia was induced. The patient was then prepped and draped. A formal time-out procedure was then performed. Using the preoperatively placed marks, the right breast was addressed first. The infracentral pedicle was first deepithelialized. The excess medial and lateral breast tissue was excised, with care to remove all external open wounds. The infracentral pedicle was then freed from its superior breast flap. The superior breast flap was then raised from the chest wall to the level of the clavicle. The medial, lateral and central breast flaps were then thinned to the appropriate size. The medial and lateral skin flaps were then tailored to the appropriate size. The wound was then irrigated with antibiotic-containing solution. Meticulous hemostasis was then achieved. 800gm of powdered matristem was applied the wound edges and regions of active hidradenitis excision. The wounds were then closed in layers, beginning with interrupted deep 3-0 Biosyn, followed by interrupted deep dermal 3-0 Biosyn.
The left breast was then addressed. Again, using the preoperatively placed marks, the infracentral pedicle was deepithelialized. The excess medial and lateral breast tissue was excised, with care to remove all external open wounds. . The infracentral pedicle was then freed from its superior breast attachments and the superior breast flap was elevated from the chest wall to the level of the clavicle. Again, the excess tissue from the superior, medial and lateral breast flaps were thinned. The medial and lateral skin flaps were tailored to the appropriate size. Care was taken to ensure symmetry at this point. After symmetry was noted, the wound was again irrigated with antibiotic-containing solution and meticulous hemostasis was achieved. 800gm of powdered matristem was applied the wound edges and regions of active hidradenitis excision. The wound was then closed using interrupted deep 3-0 Biosyn, followed by interrupted deep dermal 3-0 Biosyn.
Nipple position was then marked, noting a position 6 cm from the inframammary crease and 9.5 cm from the marked midline. The patient was placed into a sitting position where nipple symmetry was noted, as was breast size and shape. The patient was placed back into a supine position, where the incisions were made sharply full thickness. The subcutaneous tissue was divided with electrocautery. The nipples were then delivered through the incision, 100gm of powdered matristem was applied to the wound edges and the nipple inset using interrupted deep dermal 3-0 Biosyn. All incisions were then closed with a running 4-0 Biosyn subcuticular stitch. Benzoin followed by Steri-Strips were applied to the incisions.
The left axilla wound was inspected and noted to be under tension, therefore excision of this tissue was not able to be done. 200gm of powdered matristem was applied to the open wound followed by a single layer 3x3.5 cm matristem wound matrix. Adaptic and surgilube was then applied and a bolster dressing was secured with 4-0 nylon. The patient was placed into dressings consisting of dressing sponges, followed by circumferentially placed Kerlix and Ace wraps. The patient was allowed to awaken from anesthesia. The LMA device was removed and she was transferred to the postanesthetic care unit in stable condition. The patient tolerated the procedure well without complications. Counts were correct