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Bilateral Upper Lid Blepharoplasty Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Brow ptosis with asymmetry.
2. Bilateral upper lid blepharochalasis.
3. Bilateral lower lid blepharochalasis.
4. Submental lipodystrophy.

POSTOPERATIVE DIAGNOSES:
1. Brow ptosis with asymmetry.
2. Bilateral upper lid blepharochalasis.
3. Bilateral lower lid blepharochalasis.
4. Submental lipodystrophy.

OPERATIONS PERFORMED:
1. Right transblepharoplasty Endotine browlift.
2. Bilateral upper lid blepharoplasty.
3. Bilateral lower lid transconjunctival blepharoplasty.
4. Submental liposculpturing.

SURGEON:  John Doe, MD

ANESTHESIA:  General plus supplemental 1% lidocaine with adrenaline.

DESCRIPTION OF OPERATION:  With the patient positioned in the supine position on the operating room table, satisfactory level of general anesthesia was obtained. Attention was turned to place Thromboguards in lower extremities and pillows behind the knee. The face and neck were prepped with Betadine gel and draped in the sterile manner after instillation of Lacri-Lube ointment, both eyes. Attention was then turned to injection of the brow bilaterally with 1% lidocaine with 1:100,000 adrenaline as well as subperiosteal area of the forehead. Once this was completed, attention was turned to marking the upper eyelids and injecting 1% lidocaine with epinephrine and then a transconjunctival injection of 1% lidocaine with adrenaline was placed in both sides.

Attention was then turned to the right upper eyelid where a crease incision was made, carried down through the subcutaneous tissue. Superior dissection was then carried up to the level of the superior orbital rim. Attention was turned to scoring periosteum along the orbital rim, above the orbital fat pad, and once this was completed, attention was turned to elevating periosteum up to the upper third of the forehead using a Freer elevator. After this was completed, attention was turned to the drilling of Endotine hole 4 mm above the inferior aspect of the orbital rim. After this was completed, a 3 mm Endotine device was placed. Periosteum was suspended over the top of the Endotine and secured. After this was completed, attention was turned to opening the orbital septum. Medial and middle fat compartments were evacuated of excessive fatty tissue and attention was then turned to hemostasis. Closure was performed with subcuticular running 5-0 Prolene. Attention was then turned to the left upper eyelid where crease incision was made. Skin strip was removed. Orbicularis muscle strip was removed. The orbital septum was opened and excessive fatty tissue was resected and hemostasis was obtained.

No Endotine device was placed on the left side due to the fact that the left brow was higher than the right to begin with and attention was then turned to closure of the upper eyelid with 5-0 subcuticular Prolene. The brow was then taped superiorly with half-inch Steri-Strips in the right side and secured with transverse Steri-Strips above the level of the brow bilaterally. After this was completed, the attention was then turned to the lower eyelid. Starting on the right side, a transconjunctival incision was made with the Colorado-tip Bovie. Traction suture, 6-0 silk, was placed on the superior conjunctival flap. Oblique dissection was carried towards the orbital rim until the fat compartments were opened. The medial, middle, and lateral fat compartments were evacuated of excessive fatty tissue and hemostasis was obtained. Closure of the conjunctiva was now done with interrupted buried 6-0 rapidly absorbing gut.

Attention was then turned to the left lower eyelid where the exact same procedure was performed without complications. After this was completed, the eyes were irrigated with balanced salt solution, two drops of tetracaine were placed in each eye, and Polysporin ophthalmic ointment was placed. Attention was turned to placing 1% lidocaine with 1:100,000 adrenaline in the previously marked areas of the neck. After adequate hemostasis was obtained, cross-tunneling liposculpturing was performed using decreasing caliber Klein cannulas until adequate contour in submental regions was performed. All areas expressed excessive fluid. Closure was performed with 5-0 nylon and a compression facial garment was applied after cleansing the face, removing all Betadine paint. The patient tolerated the procedure well. Ice compressors applied to the eyes. The patient was transferred to the recovery room in excellent condition.

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