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Secondary Rhytidectomy Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Facial cutis laxa.
2.  Glabellar rhytids.

POSTOPERATIVE DIAGNOSES:
1.  Facial cutis laxa.
2.  Glabellar rhytids.

OPERATION PERFORMED:
1.  Secondary rhytidectomy.
2.  Radiesse injection into glabellar creases.

SURGEON:  John Doe, MD

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:
This is a (XX)-year-old female who had undergone rhytidectomy approximately 8 years ago.  The patient now presents with recurrent facial cutis laxa. Physical examination revealed healed rhytidectomy scars with submental laxity and jowling. The patient also demonstrated asymmetrically deep glabellar rhytids, greater on the left side than on the right.

DESCRIPTION OF OPERATION:
The patient was brought to ambulatory care in supine position and was prepped and draped in the sterile fashion under IV sedation. Ancef 1 gram was administered intravenously. A total of 13 mg of Versed and Demerol 112.5 mg was administered intravenously during the course of the procedure. Xylocaine 1% with epinephrine diluted with saline was injected in the submental area in the right and left facial planes.

An ellipse of skin was removed around the previous submental scar. Dissection was carried down to the level of the platysma. A submental pocket was created. This was irrigated with bacitracin and checked for hemostasis. Submental platysmal plication was performed with 4-0 Vicryl suture. Incision was closed with 4-0 Vicryl suture. The right facial plane was then elevated by creating an incision in the previous temporal rhytidectomy scars, then extending down towards the ear, closer to the tragus, around the earlobe, around the postauricular sulcus, down the occipital hairline. Flap was elevated and the wound was irrigated with bacitracin irrigation.

SMAS plication was performed in the preparotid platysmal area with 4-0 Vicryl suture. The flap was then drawn superiorly and posteriorly and anchored at the root of the helix and the superior-posterior auricular sulcus with 2-0 nylon suture. Redundant skin and soft tissue was then removed from the temporal area, the periauricular area, the postauricular area, and the occipital area. Then, 4-0 Vicryl suture was used to further approximate the flap. Staples were placed in the temporal area and 4-0 nylon in the postauricular area.

Upon completion of the right facial rhytidectomy, a similar procedure was performed on the left side. Once again the flap was elevated on the previous scar and brought in closer towards the tragus. Once the flap was elevated, the pocket was irrigated with bacitracin and checked for hemostasis. A second SMAS plication was performed with 4-0 Vicryl suture similar to the opposite side. The flap was drawn superiorly and posteriorly and anchored at the root of the helix and the superior and posterior auricular sulcus with 2-0 nylon suture. Redundant skin and soft tissue was removed from the temporal area, the preauricular area, the postauricular area, and the occipital area. The flap was then set with 4-0 Vicryl suture followed by staples in the temporal area and 4-0 nylon in the postauricular area.

Once this was completed, Radiesse was then injected in the bilateral glabellar creases. Bacitracin and Adaptic were placed on the incisions followed by fluffs, Kerlix, and a Kling. The patient tolerated the procedure well and was discharged in stable condition.

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