Bilateral Reduction Mammoplasty Surgery Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:

1. Bilateral macromastia.

2. Back pain.

POSTOPERATIVE DIAGNOSES:
1. Bilateral macromastia.
2. Back pain.

OPERATION PERFORMED: Bilateral reduction mammoplasty.

SURGEON: John Doe, MD

DESCRIPTION OF OPERATION: The patient was marked out appropriately in the holding area and then brought to the operating room in supine position, prepped and draped in sterile fashion under general anesthesia for bilateral reduction mammoplasty. Ancef 1 gram was administered intravenously. SCD compression boots were placed on lower extremities. Right nipple-areolar complex was marked out at 42 mm diameter.

A keyhole was deepithelialized on inframammary crease. Medial and lateral segments of skin and soft tissue were removed out of the prepectoral fascia. Further tissue was removed from below both flaps as well as from below the bipedicle flap, creating McKissock reduction mammoplasty. The wound was irrigated with bacitracin and checked for hemostasis and 448 grams of tissue was removed from the right breast. Flaps were approximated with 2-0 Vicryl suture and 4-0 Vicryl and subcuticular 4-0 Monocryl. Surgical staples were then placed for further support at anchoring points.

On completion of right reduction mammoplasty, there was excellent viability of the nipple-areolar complex and the breast flaps themselves.

A similar procedure was performed on the large left breast. Once again the nipple-areolar complex was marked out at 42 mm diameter.

The keyhole was deepithelialized on inframammary crease. Medial and lateral segments of skin and soft tissue were removed out of the prepectoral fascia. Further tissue was removed from below both flaps as well as from below the bipedicle flap, creating a second McKissock reduction mammoplasty and 626 grams of tissue was removed from the left breast.

The wound was irrigated with bacitracin and checked for hemostasis. Flaps were approximated with 2-0 and 4-0 Vicryl suture followed by subcuticular 4-0 Monocryl. Surgical staples were again placed at anchoring points for further support.

On completion of left reduction mammoplasty, there was excellent viability to the nipple-areolar complex and breast flaps themselves. Mastisol and Steri-Strips were placed on the incisions followed by fluff and a surgical bra.

The patient tolerated the bilateral reduction mammoplasty well and was discharged in stable condition to the recovery room.