ABOUT: Particularly when just starting residency, dictating efficient and concise operative notes can be somewhat daunting. We have compiled a list of common dictation examples to get you started. Please also refer to our Surgical Video Atlas, Podcast, and 3D Temporal Bone Atlas for related content. Remember, operative notes carry significant medicolegal implications and it is your responsibility to document accurate and clear notes that reflect the specific details of your procedure. These are only examples and all dictations must be adapted to the particular encounter.
In addition to the describing the surgical narrative, most operative notes include these additional entries, but this may vary according to specific institutional preferences:
PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___
FACIAL PLASTICS TABLE OF CONTENTS
SEPTORHINOPLASTY WITH BILATERAL INFERIOR TURBINATE REDUCTION
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the bed was rotated 90 degrees. ___ ccs of ___% lidocaine with ___ epinephrine were injected into the nose, and the nasal cavities were decongested using cottonoid soaked with ___. The patient was then prepped and draped in the usual fashion. A surgical pause was then performed, in which the patient's identity and procedure were confirmed.
The procedure was begun with bilateral submucous inferior turbinoplasty. A 2-mm microdebrider was used to debulk the inferior turbinate soft tissue, following which the anterior halves of the conchal bones were removed via anteroinferior marginal incisions using a #___ blade and ___ forceps. The turbinates were then outfractured using a ___ elevator.
The nose was then opened via an inverted V transcolumellar incision and marginal incisions using a #___ blade. The skin-soft tissue envelope was elevated off the underlying cartilages with a combination of ___ scissors, and a ___ periosteal elevator. A coarse rasp was then used to reduce the dorsal hump, following which, the interdomal ligaments were divided, exposing the anterior septal angle. A submucoperichondrial plane was developed on either side of the quadrangular cartilage, and bilateral flaps were elevated past the bony-cartilaginous junction. Keeping a ___-mm wide L-strut intact, the central portion of the quadrangular cartilage and the deviated portion of the bony septum were resected with ___ shears and ___ forceps. Care was taken to leave keystone area undisturbed. After careful elevation of the mucoperichondrium from the internal valves, the upper lateral cartilages were disarticulated from the dorsal septum using a #___ blade.
At this time, attention was directed to the bony vault. Bilateral intranasal high-low-high lateral osteotomies and medial osteotomies were made. The bony segments were then shifted into the midline in order to close the open roof of the bony vault. Tapered spreader grafts measuring ___-mm in length were affixed on either side of the dorsal septum using ___-0 ___ sutures, following which the midvault was reconstructed using 2 horizontal mattress sutures of ___-0 ___, which resuspended the upper lateral cartilages to the spreader grafts and dorsal septum. The tip was then reconstructed with a columellar strut graft, fashioned from harvested septal cartilage, placed between the medial crura and secured with ___-0 ___suture. Interdomal sutures were then placed, again using ___-0 ___, taking care to maintain separation of the domes in order to preserve natural tip bifidity. Bilateral cephalic trims of the lateral crura were performed, leaving complete strips of ___-mm in width intact.
The skin-soft tissue envelope was then redraped and the transcolumellar incision closed with interrupted ___-0 ___centrally and ___-0 ___ suture laterally. The marginal incisions were closed with interrupted ___-0 ___ suture, and a quilting stitch was placed using ___-0 ___. The stab incision in the radix was closed with Dermabond, and ___ splints were placed on either side of the nasal septum, then secured transseptally with a ___-0 ___ suture. Half-inch steristrips were applied, followed by a nasal cast.
The stomach was suctioned via an orogastric tube. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
SMAS FLAP FACE LIFT
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the bed was rotated 90 degrees. The patient was then prepped and draped in the usual fashion. A surgical pause was then performed, in which the patient's identity and procedure were confirmed.
A total of ___ ccs of ___% lidocaine with ___ epinephrine was injected into the bilateral mid and lower faces as well as the submental region. The injections were carried out throughout the course of the procedure. The procedure was begun with an approximately ___-cm submental incision that was made with a #___ blade in a preexisting skin crease. A supraplatysmal flap was raised down to the level of the hyoid bone with ___ scissors, allowing exposure of the submental fat pad, a portion of which was resected. The platysmal muscles were identified and the medial borders were isolated. The medial borders were then sutured together with simple interrupted ___-0 ___, sutures taking care to bury the knots. Hemostasis was achieved with bipolar electrocautery.
Attention was then directed to the right face where a Blair incision was made with a #___ blade, running from the temporal scalp anteriorly to the root of the helix, beveled parallel to the hair follicles, then posterior to the tragus, anterior to the lobule, up the posterior aspect of the auricle one-third of the way between the sulcus and the helical rim, and then back into the hairline across the shortest distance of non-hair-bearing skin. Care was taken to bevel the incision parallel to the hair follicles in the temporal scalp. The flap was raised, again using ___ scissors, extending approximately 5-cm anterior to the auricle and staying in a subdermal plane. Flap elevation was continued around posteriorly into the mastoid scalp using a combination of ___ and ___ scissors. This dissection was ultimately made contiguous with the submental dissection.
The SMAS overlying the parotid gland was incised in order to elevate a roughly 1 x 8-cm inferiorly based flap located approximately 1-cm anterior to the tragus, terminating superiorly at the level of the superior aspect of the zygomatic arch and inferiorly at the angle of the mandible. This flap was transposed postauricularly and tension was applied before it was anchored to the mastoid periosteum, again using buried ___-0 ___ sutures in order to tighten the jawline and reduce the jowls.
The defect in the SMAS was then closed by imbrication, again with buried ___-0 ___ sutures, such that the anterior edge of the incision was pulled superiorly to provide suspension for the midfacial soft tissues, anchoring the SMAS anterior to the incision to the temporalis fascia. The posterior border of the platysma was also pulled superoposteriorly and suspended to the mastoid periosteum, again using buried ___-0 ___ sutures. This had the effect of further suspending the soft tissues of the neck and restoring a youthful cervicomental angle. At this time, hemostasis under the flaps was achieved with bipolar electrocautery.
Attention was directed to the left side where the same procedure was performed. Once both facial flaps were elevated and the SMAS was suspended, ___ drains were placed into the neck via posterior ends of the incisions, thereby eliminating dead space and decreasing the risk of hematoma or seroma collection postoperatively.
The flap edges were then tailored with a combination of a #___ blade and ___ scissors, and the wounds were closed in layers. The submental incision was closed with ___-0 ___ deep dermal sutures and running ___-0 ___ in the skin. The temporal aspect of the incision was closed with ___-0 ___ and running ___-0 ___ suture. The preauricular aspect of the incision was closed with ___-0 ___ and running ___-0 ___ suture. The post-tragal aspect was closed with interrupted ___-0 ___. The postauricular aspect was closed with ___-0 ___ and ___-0 ___.
Ointment was then applied to the incisions and a ___ pressure dressing was placed over ice packs. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition where her great auricular and facial nerves were noted to be intact. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
DEEP PLANE FACE LIFT
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the bed was rotated 90 degrees. The patient was then prepped and draped in the usual fashion. A surgical pause was then performed, in which the patient's identity and procedure were confirmed.
A total of ___ ccs of ___% lidocaine with ___ epinephrine was injected into the bilateral mid and lower faces as well as the submental region. The injections were carried out throughout the course of the procedure. The procedure was begun with an approximately ___-cm submental incision that was made with a #___ blade in a preexisting skin crease. A supraplatysmal flap was raised down to the level of the hyoid bone with ___ scissors, allowing exposure of the submental fat pad, a portion of which was resected. The platysmal muscles were identified and the medial borders were isolated. The medial borders were then sutured together with simple interrupted ___-0 ___, sutures taking care to bury the knots. Hemostasis was achieved with bipolar electrocautery.
Attention was then directed to the right face where a Blair incision was made with a #___ blade, running from the temporal scalp anteriorly to the root of the helix, beveled parallel to the hair follicles, then posterior to the tragus, anterior to the lobule, up the posterior aspect of the auricle one-third of the way between the sulcus and the helical rim, and then back into the hairline across the shortest distance of non-hair-bearing skin. Care was taken to bevel the incision parallel to the hair follicles in the temporal scalp. The flap was raised, again using ___ scissors, continuing in a subdermal plane until reaching a line between the angle of the mandible and the malar eminence. Flap elevation in the subdermal plane was continued around posteriorly into the mastoid scalp using a combination of ___ and ___ scissors. This dissection was ultimately made contiguous with the submental dissection.
Using a #___ blade, an incision was then made in the SMAS, running along a line between the angle of the mandible and the malar eminence. Elevation in the deep plane then proceeded bluntly towards the nasolabial fold using a combination of the back end of ___ forceps and cotton-tipped applicators. Care was taken to elevate the malar fat pad off the underlying zygomaticus major muscle, keeping the fat attached to the undersurface of the flap and leaving the zygomaticus major intact. During the dissection, several distal branches of the facial nerve were identified and left intact.
The anterior cut edge of the SMAS was then suspended posterosuperiorly to the temporalis fascia and the SMAS overlying the parotid gland using buried ___-0 ___ sutures in order to apply tension to the middle and lower face, repositioning the malar fat pad, and effacing the nasolabial folds and jowls. The posterior border of the platysma was also pulled superoposteriorly and suspended to the mastoid periosteum, again using buried ___-0 ___ sutures. This had the effect of further suspending the soft tissues of the neck and restoring a youthful cervicomental angle. At this time, hemostasis under the flaps was achieved with bipolar electrocautery.
Attention was directed to the left side where the same procedure was performed. Once both facial flaps were elevated and the SMAS was suspended, ___ drains were placed into the neck via posterior ends of the incisions, thereby eliminating dead space and decreasing the risk of hematoma or seroma collection postoperatively.
The flap edges were then tailored with a combination of a #___ blade and ___ scissors, and the wounds were closed in layers. The submental incision was closed with ___-0 ___ deep dermal sutures and running ___-0 ___ in the skin. The temporal aspect of the incision was closed with ___-0 ___ and running ___-0 ___ suture. The preauricular aspect of the incision was closed with ___-0 ___ and running ___-0 ___ suture. The post-tragal aspect was closed with interrupted ___-0 ___. The postauricular aspect was closed with ___-0 ___ and ___-0 ___.
Ointment was then applied to the incisions and a ___ pressure dressing was placed over ice packs. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition where her great auricular and facial nerves were noted to be intact. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
DIRECT BROW LIFT
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the patient was prepped and draped in sterile fashion; ___ ccs of ___% lidocaine with ___ epinephrine were then injected into the marked brow excisions. A surgical pause was then performed, in which the patient's identity and procedure were confirmed.
A #___ blade was used to make the marked incisions, and then the skin was excised with ___ scissors; tissue was removed down to the level of the frontalis muscle, taking care to avoid exposure of an injury to the supraorbital and supratrochlear neurovascular bundles. Hemostasis was achieved with bipolar electrocautery on a setting of ___ watts.
The inferior edge of the incision was then suspended to the periosteum above the superior edge of the incision using two ___-0 ___ sutures, one medial and one lateral, following which, the incisions were closed with interrupted, buried ___-0 ___ deep dermal sutures and running ___-0 ___ in the skin. Ophthalmic ointment was applied to the incisions, followed by a ___ mask. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
ENDOSCOPIC BROW LIFT
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The peaks of the brow arches were marked. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the bed was rotated 90 degrees. The frontal and temporal scalp were injected ___ ccs of ___% lidocaine with ___ epinephrine. The patient was then prepped and draped in sterile fashion and a surgical pause was performed in which the patient's identity and procedure were verified.
Incisions were made in the midline and bilateral paramedian frontal scalp, directly superior to the marked brow peaks. These incisions were placed approximately 1 cm behind the hairline and carried down to the bone. Periosteum was then elevated using ___ and ___ elevators, and the central forehead compartment was opened down to the level of the orbital rim without the use of an endoscope. Back elevation toward the vertex of the skull was also performed for a distance of approximately 4 cm. The temporal incisions were then made within the temporal hair tufts, taking care to bevel the scalpel in order to remain parallel to the hair follicles. These curvilinear incisions were approximately 3 cm long and centered on lines running through the lateral alae to the lateral canthi, with the convex aspect of the incision facing anteriorly. The incisions were then carried down through the temporoparietal fascia and onto the temporalis fascia, using ___ scissors. A ___ elevator was used to elevate the temporoparietal fascia off the temporalis fascia and avulse the conjoint tendon from medial to lateral, in order to make the lateral and central compartments contiguous.
The 30-degree rigid endoscope with optical dissector sheath was then through the midline scalp port and additional elevation of the periosteum was performed down to the level of the orbital rim bilaterally under endoscopic visualization. The supraorbital neurovascular bundles and corrugator supercilii muscles were identified and preserved bilaterally. The sentinel veins were identified and preserved as well, during the lateral dissection in order to expose the lateral orbital rim. The arcus marginalis was then divided from lateral canthus to lateral canthus and spread using a ___ elevator until fat was clearly visualized along the entire length of the incision. Once the elevation was complete, a single well was drilled in each paramedian incision, aligned vertically above the peaks of the brows, and 3 mm Endotine devices were placed. The forehead was then pulled superiorly with double-pronged skin hooks and the periosteum fixated to the Endotines. The patient's head was elevated and the brows evaluated for symmetry. Once acceptable symmetry was achieved, the median and paramedian incisions were closed in layers with ___-0 ___ deep dermally followed by running ___-0 ___ in the skin. The temporal incisions were then converted to elliptical excisions and closed in layers. The deep layer was closed with the temporoparietal fascia of the anterior aspect of the incision being tacked to the temporalis fascia using ___-0 ___ in order to provide temporal lift. The skin was then closed with ___-0 ___ buried deep dermal suture followed by running ___-0 ___ on the surface.
The scalp was cleaned and dried, and ointment was applied to the incisions. A ___ dressing was applied. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
TRICHOPHYTIC BROW LIFT
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The peaks of the brow arches were marked. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the bed was rotated 90 degrees. The frontal and temporal scalp were injected ___ ccs of ___% lidocaine with epinephrine. The patient was then prepped and draped in sterile fashion and a surgical pause was performed in which the patient's identity and procedure were verified.
An incision was marked running from the root of the helix, up through the temporal hair tuft, across the forehead at the hairline, then back into the temporal tuft and down to the helical root. The incision was then made with a #___ blade, taking care to bevel parallel to the hair follicles. The incision was carried down to bone centrally; lateral to the temporal lines, the incision went down to the temporalis muscle fascia. The periosteum was then elevated using a ___ elevator, and the central forehead compartment was opened blindly down to the level of the orbital rim. Laterally, the temporoparietal fascia was elevated off the temporalis fascia and the conjoint tendon divided with ___ scissors in order to make the lateral and central compartments contiguous. Care was taken to ensure complete elevation of temporoparietal fascia superolateral to the brow in order to prevent facial nerve injury.
The forehead flap was then reflected inferiorly using ___ doubled-pronged skin hooks and the supraorbital rim visualized. The supraorbital neurovascular bundles were identified and preserved, and the foramina released inferiorly using a 3 mm osteotome to permit mobilization of the neurovascular bundles and complete exposure of the supraorbital rim. The periosteum of the orbital rim was elevated laterally to the level of the lateral canthi using a ___ elevator. The arcus marginalis was then divided using a #___ blade and spread with a ___ elevator until fat was visible.
The forehead flap was then reflected back into position and retracted superiorly with ___ double-pronged skin hooks, one placed at each brow peak. Excess forehead skin was incised and the forehead flap tacked to the scalp with ___-0 interrupted ___ sutures directly superior to the brow peaks. The forehead flap was then tailored with a #___ blade and hemostasis was achieved with bipolar electrocautery on a setting of ___ watts, taking care to minimize thermal injury to hair follicles.
The incision was then closed in layers, with buried, interrupted ___-0 ___ sutures used for the galea aponeurotica and temporoparietal fascia, buried, interrupted ___-0 ___ sutures in the deep dermis, and running ___-0 ___ sutures on the surface.
The scalp was cleaned and dried, and ointment was applied to the incision. A ___ dressing was applied. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
UPPER EYELID BLEPHAROPLASTY WITH FAT REMOVAL
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the patient was prepped and draped in sterile fashion. A surgical pause was then performed, in which the patient's identity and procedure were confirmed.
The upper blepharoplasty excisions were then marked using ___ forceps and calipers, taking care to leave 15-20 mm of intact upper eyelid skin between the lid margin and the inferior aspect of the brow. The medial aspects of the incisions were angled upward at the lacrimal punctum in order to prevent webbing at the canthus, and the lateral aspects of the incisions followed lateral orbital rhytides; ___ ccs of ___% lidocaine with ___ epinephrine were then injected into the upper eyelids.
A #___ blade was used to incise the skin markings, inferior aspect first. ___ scissors were used to complete the upper eyelid skin excision. A strip of orbicularis oculi muscle was then excised between the medial and lateral canthi to debulk the upper eyelid and expose the orbital septum. Gentle pressure was applied to the eyelid overlying the globe, and bulging fat was noted in the medial and central compartments. Monopolar electrocautery with a ___ tip on a setting of ___ watts was used to open the septum overlying the fat and achieve hemostasis. Excess preaponeurotic fat was carefully dissected without undue traction, then clamped with a ___ mosquito and resected with electrocautery in order to prevent intraorbital bleeding. Bipolar forceps were then run across the exposed septum to tighten it and define the supratarsal crease. Closure was accomplished in a single layer with simple, interrupted ___-0 ___ sutures.
Ophthalmic ointment was applied to the incisions, followed by a ___mask. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
LOWER LID BLEPHAROPLASTY WITH FAT TRANSFER (TRANSCONJUNCTIVAL, PRESEPTAL)
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The tear troughs were marked. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the bed was rotated 90 degrees. The conjunctiva of the lower eyelids and infraorbital nerves were injected with ___ ccs of ___% lidocaine with ___ epinephrine each. The patient was then prepped and draped in sterile fashion and a surgical pause was performed in which the patient's identity and procedure were verified.
The procedure was begun with an incision approximately 2-mm inferior to the inferior border of the tarsal plate, using a ___ Bovie on a setting of ___ watts. The incision ran from the level of the lacrimal punctum to the level of the lateral canthus, with exposure provided by a ___. The incision was carried through the conjunctiva and through the capsulopalpebral fascia. A ___-0 ___ suture was then passed through the lower eyelid retractors in two bites, retracted superiorly, and clamped in order to protect the cornea and provide countertension. The orbital septum was then identified and the orbicularis oculi muscle dissected off it with a combination of monopolar electrocautery and cotton tip applicators while exposure was provided with a ___ retractor.
Once the inferior orbital rim was identified, the orbicularis oculi muscle was bluntly separated from it with the tips of ___ blepharoplasty scissors in order to expose the periosteum and develop a pocket on the far side of the tear trough. A ___-0 ___ suture was passed through the periosteum on the far side of the tear trough and then clamped to the drapes for future use.
The orbital septum was then opened with electrocautery and pressure on the globe was used to herniate the excess fat into the operative field. Gentle traction and cautery dissection were performed in order to identify and isolate each of the three fat compartments from their fascial attachments. The inferior oblique muscle was identified between the medial and central fat compartments and preserved. Excess lateral compartment fat was clamped with a ___ mosquito and resected with electrocautery in order to prevent bleeding within the orbit. Minimal fat was similarly resected from the central and medial compartments. The previously-placed ___-0 ___ suture was then passed through the remaining medial and central fat and used to transfer the fat into the tear trough to smooth the eyelid-cheek junction. Meticulous hemostasis was achieved with electrocautery, but care was taken to avoid excess thermal injury in order to prevent cicatricial ectropion postoperatively.
The ___-0 ___ stay suture was then removed and the lower eyelid redraped. Ophthalmic ointment was applied. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
UPPER EYELID WEIGHT PLACEMENT
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The upper eyelid crease was marked on the correct side. ___ ccs of ___% lidocaine with ___ epinephrine was injected. The patient was prepped and draped sterilely. A surgical pause was then performed, in which the patient's identity and procedure were confirmed. An incision was made with a #___ blade and dissection carried down through the orbicularis oculi muscle onto the tarsal plate with ___ scissors. A pocket was created with the inferior extent 2 mm superior to the eyelid margin, centered on the medial limbus. Hemostasis was achieved with bipolar electrocautery on a setting of ___ watts and the ___ g ___ weight was placed in the pocket. Interrupted clear ___-0 ___ sutures were used to secure the weight to the tarsal plate, taking care to avoid violating the conjunctiva with full thickness bites. The orbicularis oculi was closed with buried, interrupted ___-0 ___ sutures and the skin closed with interrupted ___-0 ___ sutures. Ophthalmic ointment and a cold pack were applied. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
TARSAL STRIP LATERAL CANTHOPEXY WITH CANTHOTOMY AND CANTHOLYSIS
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the patient was prepped and draped in sterile fashion. A surgical pause was then performed, in which the patient's identity and procedure were confirmed.
The procedure was begun with injection of the lateral canthus with approximately ___ ccs of ___% lidocaine with epinephrine, taking care to inject not only the skin incision, but the soft tissue all the way down to the bone of the lateral orbital rim at the canthus as well.
A roughly 1 cm incision was then marked in a lateral canthal crow’s foot rhytid, extending laterally from the lateral canthus. The incision was then made with a #___ blade, following which, ___ scissors were used to dissect sharply down to the lateral orbital rim. The lateral aspect of the lower lid was then retracted away from the lateral canthus with ___ forceps and the inferior lateral canthal ligaments divided with ___ scissors, completely releasing the lateral attachments of the lower eyelid. Hemostasis was then achieved with bipolar electrocautery on a setting of ___ watts.
Using ___ scissors, a 5 mm back cut incision was then made inferior to the tarsal plate of the lower eyelid from lateral to medial. The skin overlying the lateral 5 mm of the tarsal plate was then removed and the gray line denuded to the same extent. The conjunctiva of the lateral 5 mm of the tarsal plate was then scraped away using the #___ blade.
A ___-0 ___ suture was then passed through the superior margin of the tarsal strip and the lateral aspect of the margin of the upper eyelid, and the ends clamped with a hemostat for future use. Both needles of a doubled-armed ___-0 ___ suture were then passed through the lateral aspect of the tarsal strip from deep to superficial. The needles were then passed through the periorbita of the lateral orbital wall, ensuring the position of the new lateral canthus was located approximately 2 mm superior to the medial canthus, and the suture was tied. The previously placed ___-0 ___ suture was then tied in order to recreate a sharp lateral canthal angle.
The orbicularis oculi muscle was then closed with buried, interrupted sutures of ___-0 ___, following which, the skin was closed with interrupted ___-0 ___ sutures.
Ophthalmic ointment was applied to the incisions, followed by a ___mask. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.
OTOPLASTY
DICTATION OF EVENTS: The patient was brought into the operating room and identified by name and medical record number. The patient was placed on the operating table in the supine position. After an adequate plane of general endotracheal anesthesia was successfully obtained by the anesthesia service, the bed was rotated 90 degrees. Marks were made with a skin marker at the top of the helix, Darwin’s tubercle, and the helix at the level of the inferior aspect of the conchal bowl. The distances between these marks and the mastoid skin were measured and recorded. The postauricular excisions were then marked as ellipses extending from approximately 15 mm inferior to the superior apex of the helix down to the level of the base of the conchal bowl, set approximately 15 mm medial to the helical rim. ___ ccs of ___% lidocaine with ___ epinephrine were then injected into the posterior auricles, postauricular sulci, and mastoid subcutaneous tissue. The patient was then prepped and draped in the usual sterile fashion and a surgical pause was performed in which the patient's identity and procedure were verified.
The procedure was begun with the postauricular excision using a #___ blade and monopolar electrocautery on a setting of ___ watts. The skin and soft tissue were removed down to the level of the perichondrium. The skin of the lateral posterior auricle was then elevated out to the edge of the cartilage with ___ blepharoplasty scissors in order to provide exposure for Mustardé suture placement. The skin of the medial posterior auricle was then also elevated towards the postauricular sulcus using electrocautery; the subcutaneous tissue overlying the mastoid was removed in order to provide room for conchal bowl setback. Care was taken to avoid transecting the external auditory canal during elevation.
At this time, attention was directed to the anterior aspect of the auricle. Horizontal mattress guide sutures of ___-0 ___ were placed transcutaneously to create an antihelical fold and superior crus. Each horizontal mattress measured approximately 10 mm long by 15 mm wide. The posterior aspect of the auricular cartilage was then visualized and the guide sutures identified. Corresponding mattress sutures were then placed through the posterior aspect of the cartilage, using ___-0 ___ suture, taking care not to pass through the anterior auricular skin. The blue guide sutures were then removed.
Attention was then directed to the conchal setback. Furnas horizontal mattress sutures of ___-0 ___ were passed from the midline of the conchal bowl curvature to the mastoid periosteum: one superior, one inferior, and one in the middle. The sutures were then tightened and tied to medialize and posteriorly shift the auricle in order to avoid stenosing the external auditory meatus; care was taken to keep tension on the sutures even in order to avoid distorting the helical rim.
Once the Mustardé and Furnas sutures were complete, the lobule was noted to be laterally malpositioned. A conservative resection of the lateral aspect of the cauda helicis was performed, which resolved the outstanding lobule.
Closure was then performed over a ___ drain using a running ___-0 ___ suture. Ointment was applied and a bilateral mastoid dressing was placed. This marked the end of the procedure. The patient was awakened, extubated, and transferred to the PACU in stable condition. All surgical pauses were observed. Standard operating room protocol and universal precautions were utilized throughout the procedure.