AI Scribe for Plastic Surgeons

OPERATIVE REPORT

PATIENT: 52-year-old female
DATE OF SURGERY: [Date]
SURGEON: [Surgeon Name], MD
ASSISTANT: [Assistant Name], MD
ANESTHESIA: General anesthesia

PRE-OPERATIVE DIAGNOSIS:
Left breast invasive ductal carcinoma, status post mastectomy

POST-OPERATIVE DIAGNOSIS:
Left breast invasive ductal carcinoma, status post mastectomy

PROCEDURE PERFORMED:
Left breast tissue expander placement for delayed breast reconstruction

INDICATIONS:
52-year-old female who underwent left mastectomy for invasive ductal carcinoma 6 months ago. Completed adjuvant chemotherapy and radiation therapy. Now presents for first stage of breast reconstruction. Patient counseled on tissue expander followed by implant exchange vs autologous reconstruction. Patient elects for implant-based reconstruction. Risks including infection, capsular contracture, implant malposition, radiation-associated complications, and need for revision discussed. Patient provided informed consent.

FINDINGS:
- Well-healed mastectomy scar
- Adequate skin quality and perfusion
- Adequate pectoralis major muscle
- Symmetric inframammary folds

PROCEDURE DETAILS:
Patient positioned supine with left arm abducted. Prepped and draped in sterile fashion.

Prior mastectomy scar excised and incision extended as needed for exposure. Dissection carried through subcutaneous tissue to pectoralis major muscle.

Subpectoral pocket created by elevating pectoralis major muscle from chest wall starting at sternal border and extending laterally. Dissection continued inferiorly to inframammary fold. Muscle released from inferior costal attachments to allow adequate pocket size.

Hemostasis meticulously achieved with electrocautery. Pocket irrigated with antibiotic solution (bacitracin).

500cc tissue expander (Allergan Style 133) prepared and filled with 100cc of sterile saline to check for leaks. Expander inserted into subpectoral pocket. Positioned appropriately with apex at inframammary fold. Fill port oriented laterally for easy access.

Additional 50cc saline injected for initial expansion (total 150cc). Adequate lower pole expansion confirmed. No evidence of skin compromise. Expander stable in pocket.

AlloDerm (4cm x 8cm) sewn to inferior border of pectoralis muscle with 2-0 Vicryl interrupted sutures. Inferior edge of AlloDerm sutured to chest wall at inframammary fold to provide lower pole support and define breast footprint.

12F round Blake drain placed in pocket and brought out through separate stab incision laterally. Secured with 2-0 nylon.

Wound irrigated copiously with antibiotic solution. Pectoralis muscle approximated to AlloDerm with 2-0 Vicryl. Subcutaneous tissue closed with 3-0 Vicryl. Skin closed with 4-0 Monocryl subcuticular and Dermabond.

Sterile dressing applied.

IMPLANTS/MATERIALS:
- Allergan 133 tissue expander 500cc (Lot #[number])
- AlloDerm 4x8cm (Lot #[number])

ESTIMATED BLOOD LOSS: 50 mL
DRAINS: 12F Blake drain x1
COMPLICATIONS: None

DISPOSITION:
Patient tolerated procedure well and transferred to PACU in stable condition. Drain care instructions provided. Post-operative pain management initiated. First expansion scheduled in 2 weeks. Will expand weekly to goal volume of 500cc, then allow 2-3 month maturation before exchange to permanent implant.