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DATE OF SURGERY: 11/09/2009
SURGEON
ASSISTANT
PREOPERATIVE DIAGNOSIS
Deformity, left breast, status post mastectomy, chronic drainage of right
nipple.
POSTOPERATIVE DIAGNOSIS
Deformity, left breast, status post mastectomy, chronic drainage of right
nipple.
OPERATIVE PROCEDURE
Injection of methylene blue dye, right breast, deep axillary sentinel node
biopsy, right total simple mastectomy, skin and nipple sparing, human dermal
graft, insertion of tissue expander, revision, left reconstructed breast,
left chest wall advancement flap.
ANESTHESIA
General.
ESTIMATED BLOOD LOSS
200 mL.
PREOPERATIVE SITUATION
The patient is status post left total mastectomy. She had a TRAM flap
reconstruction and developed ischemic infectious problems and lost a good
portion of the flap on the left side. She has had a number of procedures.
She now enters for further revision of the flap. The flap sits too vertical
and too inferior. She has had chronic drainage out the right nipple. She has
had a previous excisional biopsy that was negative.
The patient has been extremely anxious about the status of her right breast,
as the presenting symptoms on the left were exactly the same, with nipple
drainage and a lesion that could not be visualized on mammogram. She has
strongly requested that she have a right total simple mastectomy. The nature
of the surgery, its expected outcome, limitations, and risks were discussed
with her preoperatively.
OPERATIVE PROCEDURE
After induction of general anesthesia, a Foley catheter was placed,
alternating pressure stockings. Her arms were placed onto a well-padded arm
board, and she was then prepped and draped in the usual manner. The superior
medial and the proximal portion of the inferior aspect of the incision on
the left breast was opened, and then flaps were developed out to the
periphery of the breast. The breast was mobilized off the chest wall,
leaving a very broad base of attachment inferiorly. The lower portion of the
flap was separated from the muscle to allow a clockwise transposition of the
tissue and superior and medial displacement, putting the tissue in a more
anatomic position in the lower part of the breast. This gave a VY
advancement flap type of procedure. After mobilizing the flap, it appeared
to have good bleeding around the edges. The left chest wall was dissected
up, and a chest wall advancement flap was designed so that the vertical
portion of the wound could be closed. After freeing up the chest wall back
away from the edge approximately 15 cm and then inferiorly 15 cm, tissue was
advanced superiorly and medially and closed with interrupted suture,
advancing the flap a total of about 5.5 cm. The flaps were held in position
with interrupted Vicryl, interrupted and running Monocryl suture. The
Scarpa's fascia from the abdominal portion of the flap was then anchored to
the periphery of the breast wound that had been created by elevating skin
flaps. This was done with 2-0 Vicryl. The edges were trimmed and then inset
with interrupted and running 3-0 Monocryl and interrupted Rapide suture.
Attention was then directed to the right breast. An incision was made from
the 3 to 9 o'clock position with a lateral extension. The nipple and areola
was elevated off the breast tissue. The duct tissue was dissected out and
then sent for frozen section. No tumor was identified. Flaps were then
developed out to the periphery of the breast circumferentially using scissor
dissection and electrocautery. The breast tissue was then elevated off the
pectoralis major and serratus anterior muscles using electrocautery and
carried up into the axillary tail region. The breast tissue was removed
intact, leaving just the axillary nodes. The breast tissue weighed 216
grams. Using the gamma probe, the deep axillary space was identified, and an
area of high gamma output was identified. Two nodes were dissected out and
then traction sutures were placed. They were dissected free from the
axillary tissue using hemoclips and electrocautery. Prior to undertaking any
surgery, 1.5 mL of methylene blue was injected into sub-nipple tissue on the
right breast. The breast had been oriented with sutures and reviewed with
pathology, with two long sutures at 12 o'clock, one long at 6, two short on
the anterior surface directly beneath the nipple. The sentinel nodes came
back negative for metastatic disease.
The wound was copiously irrigated, and then after getting complete and total
hemostasis after multiple irrigations, the inferior edge of the pectoralis
major muscle was detached from the chest wall, and a submuscular pocket was
developed up over the anterior portion of the pectoralis minor muscle. The
anterior edge of the serratus anterior muscle was taken down into the
midaxillary line. A 6 x 16 piece of HD Flex dermal graft was chosen; code
#471616, serial #00309044771002A was used. It was oriented so the dermal
side faced out. It was trimmed and then inset inferiorly with interrupted
and running 0 Vicryl suture. Interrupted Vicryl sutures were placed along
the superior edge into the pectoralis major muscle. Two Blake drains were
brought out through separate stab wounds and secured with nylon suture. One
15 Blake drain was brought out laterally on the left side prior to closure
of that wound. The expander was checked to make sure that there was no leak,
and after evacuating the air, it was placed into the pocket and situated,
and then the suture tabs were sutured to the chest wall with 2-0 silk
suture. 60 mL of sterile saline was placed into the implant, and then the
previously placed 0 Vicryl sutures were tied, placing the implant in a
completely buried submuscular, subdermal space.
The wound had been irrigated multiple times with bacitracin solution. Skin
edges were trimmed, and then the wound was closed with interrupted and
running 3-0 Monocryl and interrupted Rapide suture. A well-padded sterile
dressing was placed. The estimated blood loss was 200 mL. She was extubated,
transferred to a bed after placing a sterile dressing, and brought to the
recovery room breathing spontaneously in satisfactory condition.