Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Septoplasty, Rhinoplasty, Blepharoplasty Operative Sample Report


1.  Aging face.
2.  Blepharochalasis.
3.  Nasal deformity.
4.  Deviated nasal septum.

1.  Aging face.
2.  Blepharochalasis.
3.  Nasal deformity.
4.  Deviated nasal septum.

1.  Septoplasty.
2.  Cosmetic rhinoplasty.
3.  Bilateral upper eyelid blepharoplasties.
4.  Bilateral lower eyelid blepharoplasties.
5.  Facelift.

SURGEON:  John Doe, MD


DESCRIPTION OF OPERATION:  The patient's face and upper eyelids were marked in the sitting position in the holding area.  The patient was then brought to the operating room and placed on the OR table in the supine position.  General anesthesia was induced and a Foley catheter was placed in the bladder.  The entire face was prepped and draped in aseptic fashion.  Lidocaine 1% with epinephrine was infiltrated into the upper and lower eyelids.  Later, the same local anesthetic was injected in the periauricular areas.  Upper eyelid blepharoplasties were performed by excising excess skin from each upper eyelid as marked, using a #15 blade.  A strip of orbicularis oculi muscle was resected with tenotomy scissors, thereby opening each orbital septum.  Excess fat from medial and central compartments was bipolar cauterized and resected.  Hemostasis was achieved in each upper lid with bipolar cautery and a 6-0 Prolene suture was used to close the upper eyelid incisions.  Attention was then turned to the lower eyelids.  A subciliary incision was made in each lower lid and skin muscle flap was elevated on each side.  Excess fat from the medial, central, and lateral compartments was bipolar cauterized and resected.  Excess skin and muscle was then resected with tenotomy scissors.  Hemostasis was achieved in each lower lid with bipolar cautery.  A 6-0 Prolene suture was used to close each lower lid incision.

Attention was then turned to the face.  A periauricular incision was made around each ear and a submental incision was made with a #15 blade.  A subcutaneous skin flap was elevated in the submental and submandibular area, thereby exposing each platysma muscle.  The medial border of the platysma muscles were sutured together with 3-0 Vicryl suture.  Distal to the hyoid bone, the medial border of each platysma muscle was incised with Metzenbaum scissors.  The skin flaps were then elevated across each cheek and each side of the neck using face-lift scissors.  Undermining was carried all the way across the underside of the neck until the submandibular pocket was reached.  A SMAS layer was elevated on each side to help correct the neck ptosis.  A 3-0 Mersilene suture was used to plicate the SMAS layer on each side.  Skin flaps at this point were retracted with Allis clamps and redundant skin around each ear was resected.  A layered closure was performed on each side of the neck over TLS drains using 4-0 Vicryl in the dermal layer and 5-0 and 6-0 Prolene in the periauricular skin layers.  The submental incision was closed in layers using 4-0 Vicryl and 5-0 PDS.

A face-lift dressing was applied at this point and attention was turned to the nose.  Lidocaine 1% with epinephrine was infiltrated intranasally, 5 mL was used.   A #15 blade was then used to make a columellar incision.  This was carried intranasally on each side of the rim incision.  The nasal skin was thereby elevated with tenotomy scissors, elevating skin from the lower lateral cartilages, upper lateral cartilages and nasal bones.  The septum was isolated by separating the 2 lower lateral cartilages from each other.  A Cottle elevator was used to elevate mucoperichondrial and mucoperiosteal flaps from either side of the septum.  Generous dorsal and caudal septum was preserved and intervening deviated cartilaginous septum was resected.  The perpendicular plate of the ethmoid bone which was also deviated was resected.  A portion of the maxillary crest was also resected.  When the septoplasty was completed, attention was turned once again to the nasal bones.  Medial osteotomies were performed using curved Neivert osteotomes and lateral osteotomies were then performed using a straight Neivert osteotome.  The nasal bones were then infractured.  Excess cartilage and some bony dorsum were taken down prior to the osteotomies.  The cephalic rim of each lower lateral cartilage was resected with a #15 blade and intradermal sutures using 4-0 Vicryl were placed.  The nose was then thoroughly irrigated and suctioned and the nasal skin flap was closed with 6-0 Prolene suture.  A 5-0 chromic was used to close intranasal incisions, and at this point, a Denver splint was placed on the nose.  The patient was transferred to PACU in stable condition.  No complications.

Blepharoplasty / Open Rhinoplasty Sample      Blepharoplasty and Facelift Sample

Plastic Surgery Operative Sample Reports      Plastic Surgery Operative Sample Reports #2

MT Word Help

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites