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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.