Operative Note Report Sample:

Start your career and take advantage of the new student offers.

OPERATIVE NOTE

DATE OF OPERATION: 03/20/10
PREOPERATIVE DIAGNOSIS: Ptosis and dermachalasis of the upper lids.
POSTOPERATIVE DIAGNOSIS: Ptosis and dermachalasis of the upper lids.
OPERATIVE PROCEDURE: Ptosis repair and blepharoplasty of the upper eye lids
SURGEON: Harry Richard, M.D.
ANESTHESIA: Local with monitored anesthesia care. 
ESTIMATED BLOOD LOSS: Less than 5 cc
COMPLICATIONS: None. 

JUSTIFICATION OF THE PROCEDURE:  The patient was complaining of progressive dropping of the upper lids with excess skin hanging down over the lashes.  The skin was casting a shadow over the vision making it difficult to see.  The visual field testing was performed which demonstrated a loss of the superior visual field in the primary position.  By taping the excess skin up, there was a marked improvement in the visual field.  

DESCRIPTION OF THE PROCEDURE:  After informed consent was obtained, the patient was brought to the Operating Room.  A lip crease was marked at 9-10 mm both the lid margin.  Excess skin was outlined with a green forceps.  A 50/50 mixture of Xylocaine 1.0% with epinephrine mixed with 0.75% Marcaine with epinephrine was then injected into the upper lids.  The face was prepped and draped in the usual standard fashion.  An incision was then made over the previously marked lines with a Colorado needle.  A skin muscle flap was then excised with the Bovie cutting cautery.  Hemostasis was achieved with a Bovie.  The septum was then opened with the Bovie.  Excess medial fat was excised with a hot cautery.  A segment of levator aponeurosis was excised from the anterior border of the tarsus.  The newly cut edge of aponeurosis was then advanced and hooked to the distal aponeurosis with three 6-0 Vicryl sutures.  These were adjusted until appropriate lid height and contour were achieved.  The sutures were then passed through the subcutaneous tissue of the inferior wound margin to recreate the lid crease.  The skin was then closed with interrupted and a running 6-0 plain suture.  The patient tolerated the procedure well and left the Operating Room in good condition.