Dear - Minneapolis Plastic Surgery



Minneapolis Plastic Surgery Richard H. Tholen, M.D., F.A.C.S.PATIENT: SNOW, AARON C DATE:05/24/17PREOPERATIVE DIAGNOSIS:Female to male transgender with request for total mastectomies via periareolar (keyhole) incisions.PROCEDURE:Bilateral periareolar (keyhole) mastectomies (transgender chest masculinization).The patient was marked in the preoperative holding area in the upright position where he also received Celebrex and Robaxin.He was taken to the operating room where general laryngeal mask anesthesia was instituted, the chest prepped and draped in the usual sterile fashion and 1 g of IV Ancef and 10 mg of IV Decadron were given prior to beginning the procedure. Bilateral inferior 3 to 9 o'clock periareolar incisions were made and deepened to the glandular mass. A disc of subareolar gland was left in place to avoid nipple areola skin adhering to the pectoralis fascia and causing activation deformity. This was achieved by transecting the gland at the appropriate thickness beneath the nipple areola complex preserving this disc of tissue on each side. Infiltration was then carried out with the Hunstad infusion set utilizing 1/40% Xylocaine with 1:1,000,000 epinephrine in super-wet fashion. A puncture incision for the drain in each axilla also facilitated supramuscular subglandular infiltration as well. The left gland was separated form the subcutaneous fatty tissue with Gorney facelift scissors following which the gland was lifted from the pectoralis major utilizing piecemeal dissection with the Gorney facelift scissors and cautery. When the entire glandular mass had been removed, additional dissection was carried out under direct vision to remove any glandular remnants save for the disc beneath the nipple areola complex. Fatty tissue was contoured and meticulous hemostasis secured. Ancef irrigation was carried out and a 10-mm flat Jackson-Pratt drain placed and exited via the stab incision in the left axilla. Total gland weight was 220 grams. The periareolar incision was then closed with buried interrupted 4-0 Monocryl and attention turned to the right breast where a similar procedure was carried out. 195 grams were excised from the right breast. A 10-mm flat Jackson-Pratt drain was placed after Ancef irrigation and closure accomplished in similar fashion. By this time the Jackson-Pratt drain had filled twice on the left side so the incision was reopened and the subcutaneous mastectomy space inspected. A bleeding vessel in the axilla was found and cauterized. Irrigation was carried out and no other bleeding sites identified. The drain was flushed to ensure patency and reclosure accomplished with buried interrupted 4-0 Monocryl. Antibiotic ointment, fluff gauze dressings, ABD pads, Topifoam pads and an upper body elastic vest were then placed.The patient was transported to the recovery room in stable and satisfactory condition. Prior to discharge from the recovery area the patient and his ride were instructed in wound care, limitation of activities, signs and symptoms of acute hematoma or other problem and asked to contact my office prior to return appointment in nine days if there are questions or concern whatsoever in the interim.RHT/kssD: 05/24/17 T: 05/28/17 ___________________________ Richard H. Tholen, M.D., F.A.C.S. ................
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