PREOPERATIVE DIAGNOSES:

1.  Left breast carcinoma.

2.  Status post bilateral mastectomy performed by Dr. Marla Dudak.

POSTOPERATIVE DIAGNOSES:

1.  Left breast carcinoma.

2.  Status post bilateral mastectomy performed by Dr. Marla Dudak.

OPERATION PERFORMED:

1.  First stage right breast reconstruction using Mentor tissue expander, catalogue #354-6211, serial #5859430-043, initially inflated to 100 mL.

2.  Creation of right chest wall muscle flap resulting in complete tissue expander coverage as well as prevention of lateral migration of the implant.

3.  First stage left breast reconstruction using Mentor 354-6211 implant, serial #5859430-007, initially inflated to 100 mL.

4.  Creation of left chest wall muscle flap consisting of pectoralis minor and serratus anterior musculature with result in complete lateral and inferior muscular implant coverage as well as prevention of lateral migration of the implant.

ANESTHESIA:  General.

INDICATIONS:  The patient is a 54-year-old nurse with left breast carcinoma.  She is to undergo bilateral mastectomy with prophylactic right mastectomy to be performed by Dr. Marla Dudak.  In my office, we had a rather lengthy discussion lasting at least 45 minutes to an hour discussing our findings as well as her reconstructive options.  These options include no reconstruction.  We will use specialized pros and prothesis as well as either autogenous means of reconstruction or implant-type reconstruction.  Pros and cons of the various options were discussed in detail.  I gave her realistic expectation what to expect.  I stressed to her that despite best efforts, these reconstructive efforts will not perfectly match her current breast.  In addition, despite similar techniques, asymmetries are to be expected between the two sides.  These points were stressed to her on more than one occasion during this discussion.  I also discussed the potential complications regarding the various procedures.  During our course of discussion, she informed me that she was not interested in autogenous means of reconstruction and in fact desired implant type reconstruction.  I particularly discussed the potential complication regarding this including but not limited to bleeding, infection, severe capsular contracture resulting in potential distortion or pain, possible rupture of implant, all which may require further procedures or at times need for possible temporary or permanent removal of implant.  I discussed the effects of radiation should that be required and how it may impact the reconstructive efforts.  I informed to her that at times radiation may result in skin damage to the point where reconstruction strictly with implants may not be successful.  In this scenario, she may require flap reconstruction with or without implant.  I informed her that I no longer perform those procedures should that be required.  I just wanted to make sure that she understands upfront that she may need to see other plastic surgeons.  Again, this point was stressed to her on more than one occasion.  At this point, she discussed her option with her significant other.  She had no further questions.  I gave her lengthy informed consent process, which she has had the liberty of viewing at home.  She wishes that I proceed with the operation consisting of bilateral breast reconstruction with implant technique.

PROCEDURE IN DETAIL:  The patient was met in the preoperating holding area again where she had no further questions, and with the nursing staff present, she was marked in the upright standing position.  After Dr. Dudak completed her portion of procedure, I was left with the reconstructive efforts.  New instruments, re-draping around the side performed per my routine, the patient received prophylactic antibiotics.  SCD boots were in place.  Foley was also in place.

After routine preparation, the right breast reconstruction was addressed first.  Skin flaps examined and were noted to be with uniform thickness and with good hemostasis.  Irrigation with antibiotic solution carried out per my routine.

Pectoralis major muscle was then elevated in the superior, medial, and inferior directions to the preoperative markings.  This was performed using blunt and cautery dissection technique assisted with a lighted retractor.  Great care taken to avoid disinsertion or disruption of the origin of the pectoralis major muscle both medially and inferiorly.  These origins were completely left intact.

Attention then placed towards the lateral chest wall with serratus anterior and pectoralis minor muscle, was elevated as a sheet of muscle.  The goal is to result in complete lateral and inferolateral muscular coverage.  Additionally, because of the narrowness of her chest wall, I felt that a lateral sling would be important to prevent lateral migration of implant.  This indeed was performed using cautery technique.

A tissue expander was then chosen.  Her breast specimens weighed approximately 300 g.  I felt that 275 mL tissue expander, 354-6211 implant would be appropriate.  This indeed was brought to the operating field, tested for leaks, evacuated bare initially, prefilled with 100 mL of sterile IV saline solution.  All bubbles removed per routine.

One final check of the pocket with the lighted retractor assured perfect hemostasis.  Irrigation of the pocket carried out using antibiotic solution.  Of note, prior to handling this new implant, new gloves placed per my routine.  The implant was then placed within the pocket created.  The two muscle flaps were noted to be satisfactorily dissected, thereby allowing for complete implant coverage.  The two muscle flaps were _____ to each other using interrupted 3-0 Vicryl pop-off suture.  A drain was placed through a separate stab incision and anchored to the skin using 3-0 nylon suture.  It was directed first towards the axilla and subsequently beneath the skin flaps.  Operative findings revealed no tension whatsoever on the muscle closure.  FloSeal used per my routine.  Closure of the dermal layer then subsequently performed using interrupted 4-0 Vicryl suture.  Skin closed using running 4-0 Vicryl subcuticular suture.

Attention then placed on the left side where the same exact process took place.  Skin flaps examined and were noted to be with excellent hemostasis and with uniform thickness.  Pectoralis major muscle was elevated from the chest wall in a superior, medial, and inferior directions using both blunt and cautery dissection technique.  Cautery dissection assisted with the lighted retractor.

Attention then placed towards the lateral chest wall where serratus anterior and pectoralis minor muscle was elevated as a unit.  This was performed to satisfaction as on the right side.  Irrigation of pocket carried out with antibiotic solution.  A 10-20 drape placed overlying the skin incision.  New gloves placed per my routine.

A similar tissue expander 354-6211 was chosen.  It was tested for leaks, evacuated bare initially, prefilled with 100 mL of sterile IV saline solution with all bubbles removed per routine.  The implant was then bathed in antibiotic solution.  One final check of the pocket assured excellent hemostasis.  The prepared implant was then placed within the pocket created.  Two muscle flaps were closed overlying the implant/expander without any tension whatsoever.  This was performed using interrupted 3-0 Vicryl pop-off suture.  Drain similarly placed through a separate stab incision and anchored to the skin using 3-0 nylon suture.  The drain was directed towards the axilla and subsequently beneath the skin flaps.  After the drain was applied, FloSeal sprayed on to the muscle layer.  Closure of the skin was then subsequently performed using interrupted 4-0 Vicryl suture for the dermal layer as well as a running 4-0 Vicryl subcuticular suture for the skin layer.  Mastisol and Steri-Strips were applied to both sites.  Drain sponges applied and held in place with Tegaderm.  The breast recovered with fluffy gauze dressing held in place with a Surgi-Bra.  The patient tolerated the procedure very well without complications.  She was extubated without difficulty.  All sponge, instrument, and needle counts were correct x2.